International

In addition to the previous safety actions reported by the ATSB in occurrence report number 200402411, the operator of OGB has implemented the following procedures to be followed when its aircraft are operating in the Ujung Pandang FIR:

Offset tracks are to be flown during en-route phase of flight in all (radar and non-radar) airspace

Aircraft are to return to on track by the Indonesian FIR boundaries and for climb from, and descent to, airports.

On 02 April 2003, a Bangladesh registered McDonnell Douglas DC-10-30, S2-ACR, was climbing through 2,700 ft following departure from Chittagong - Patenga Airport, Bangladesh when the No. 1 engine failed. The EGT exceeded 1,000ºC and the engine was shutdown. The aircraft returned for an uneventful landing.

The flight data recorder (FDR) was recovered from the aircraft in April 2003. The Civil Aviation Authority of Bangladesh (CAAB) was responsible for investigating this accident and appointed an investigation committee which included the aircraft operator. The CAAB requested ATSB assistance in the recovery of data from the FDR. The Executive Director of the ATSB approved the request. The CAAB also requested that some of the investigation committee be present during the download and recovery procedure. To protect the information supplied by the ATSB to the CAAB, the operator and investigation work undertaken to assist these agencies, the ATSB initiated an investigation under theTransport Safety Investigation Act 2003.

In 2007, due to the continuing uncertainty of attendance by the Bangladesh representatives, the ATSB downloaded the FDR to enable its return to the operator. A factual report describing the recorded data found on the FDR was prepared and provided to the CAAB.

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

On 3 October 2003, Convair 580, registered ZK-KFU, was operating on a scheduled night freight flight from Christchurch to Palmerston North, New Zealand. After passing Paraparaumu Non-Direction Beacon (NDB), the crew were cleared by air traffic control for descent and approach to Palmerston North. Shortly after, the aircraft was observed on radar to enter a tightening left turn and disappear from the controller’s display. Attempts to contact the crew were unsuccessful and a search for the aircraft was commenced.

In accordance with its obligations under Annex 13 to the Convention on International Civil Aviation (Annex 13), the Transportation Safety Board of Canada (TSB) investigated the circumstances surrounding the accident involving Bell Helicopter Co 204B helicopter, registered C-GEAP, at Bonaparte Lake, British Columbia on 17 August 2003.

The pilot, the sole occupant of the helicopter, was carrying out fire suppression work and had just departed a staging site with an empty underslung water bucket. Shortly after takeoff, the engine ceased operating and, during the attempted autorotation emergency landing, the attached long line entangled a tree. The helicopter impacted the ground within a forest and was destroyed by a post-impact fire. The pilot was fatally injured.

The TSB requested that the Australian Transport Safety Bureau (ATSB) assist their investigation by sourcing specific information. In accordance Annex 13 Paragraph 5.23, the ATSB appointed an Accredited Representative to the TSB investigation to provide information related to the pilot's qualifications and recent operational history.

On completion of the TSB investigation, the final investigation report will be made available on the TSB web site.

Aircraft operator

As a result of this occurrence, the aircraft operator reported that the task cards for the job were amended and that they now require that the wiring looms and other components in the area of the stowage bins are to be inspected to ensure adequate clearance from the bins and the structure.

Aircraft manufacturer

During the comment period for the draft report, the aircraft manufacturer was requested to review the installation procedures for 747 overhead bins, to assess the benefit of including a requirement to ensure adequate clearance between the stowage bins and any adjacent structure, wiring looms and other components.

The aircraft manufacturer responded to the draft report and advised:

Based on this incident, our Service Engineering and Maintenance Manual departments reviewed the need for an inspection note for wire bundles when installing the overhead stowage bins. The results of that review were as follows:

• As stated in the draft report, the current Boeing task cards do not provide instructions on how to manage wire bundles upon re-installation of the stow bins. Instead, wire separation information including minimum clearance requirements for wire bundles is provided to operators in section 20-10-11 of Boeing Standard Wiring Practices Manual (DC-54446). Thus, the wire separation requirement is already documented to the maintainer, just not on the specific task card.
  
   
• We depend on the maintainer to possess the necessary minimum skills to return the airplane to a serviceable condition. As such, a maintainer installing stow bins should already be aware of minimum wire bundle clearance requirements. Thus, we believe that the existing maintenance documentation, along with standard practices expected of the maintainer, already addresses this issue.
  
   
• We searched our service history records and could not find any other occurrences of this issue. Thus, the 30+ years of service history we have on the 747 fleet shows that this has not been a problem with the in-service fleet.
  
   

As a result, we do not feel it is necessary to amend the stow bin installation task cards to include a requirement for inspection of wire bundle clearances. Of course, each operator could include such a requirement at their discretion.

¹ The 'C' zone is the zone on the main deck between the main cabin doors 2 and 3.
² The 'D' check is the most intensive maintenance check on an aircraft.

At the time of the drafting of this report, the manufacturer, in addition to actions taken in relation to this and earlier occurrences, was also assessing the feasibility of an on-wing inspection procedure to identify those engines which may be more susceptible to blade release.

¹ UTC - Coordinated Universal Time. Singapore local time 0030 on 18 November 2003.

On 31 January 2003, at 0621 UTC (1521 local time), an Ilyushin 76TD (IL-76TD) aircraft, registered RDPL-34141, impacted terrain near Caicido village during a landing approach, about 1 NM (1.87 km) to the northwest of Cakung Airport, Baucau, Timor-Leste. The pilot in command was the handling pilot during the descent and approaches at Baucau. The aircraft was destroyed by impact forces and a severe post-impact fire, and the six occupants were fatally injured. The occupants included the flight crew, which comprised the pilot in command, the copilot, the flight navigator and the flight engineer, and two loadmasters who did not form part of the flight crew.

At the time of the occurrence, there was low cloud near the aerodrome. Witnesses at the aerodrome estimated the cloud base to be about 1,000 ft (305 m) above ground level, and visibility to be about 1,500 m (0.8 NM).

Before the aircraft's departure from Macau, the flight crew was provided with notices to airmen (NOTAMs) and weather forecast information for the planned flight. The weather information provided to the flight crew did not include a terminal aerodrome forecast (TAF), or an aviation routine weather report (METAR) for Baucau. Those weather forecasts were not produced for Baucau.

The investigation determined that the flight crew's compliance with procedures was not at a level to ensure the safe operation of the aircraft. Before the flight crew commenced the descent into Baucau, the pilot in command briefed them that he would conduct a non-precision instrument approach at Baucau, with reference to the Baucau non-directional beacon (NDB). The flight instruments fitted in the occurrence aircraft provided readings of height, speed and distance in metric units. The pilot in command's briefing included information on the relevant heights for the missed approach procedure expressed in feet, and not in their metric equivalents. None of the other crewmembers commented on that fact. The cockpit voice recorder (CVR) data revealed that the pilot in command did not refer to the source of data that he used for the briefing on the intended NDB approach at Baucau. The pilot in command's arrival briefing also contained no information or discussion on:

• the planned altimeter subscale settings for the descent to Baucau
• the applicable minimum sector altitude (MSA) within 10 NM (18 km) of the Baucau NDB; the MSA was 9,300 ft (2,834 m) above mean sea level (AMSL)
• the commencement altitude for the runway 14 NDB approach at Baucau, which was 5,500 ft (1,676 m) AMSL
• the lowest safe altitude (LSALT) for the last route sector into Baucau, which was 4,500 ft(1,372 m) AMSL
• the applicable minimum descent altitude (height) (MDA(H)) for the approach
• the expected weather at Baucau
• the Baucau NOTAMs.

The CVR data revealed that none of the other crewmembers commented on the omission of this critical information. As a result, the arrival briefing was not effective.

Controlled airspace was established at Baucau, but air traffic services (ATS) at Baucau was only available for UN aircraft on UN troop rotation days. The NOTAMs for Baucau included that information. The occurrence aircraft was not engaged in UN troop rotation operations, and no troop rotations took place during the aircraft's approach to Baucau.

When the aircraft was about 300 km from Baucau, the pilot in command instructed the copilot to call Baucau ATS. Over the next 23 minutes, the copilot called Baucau Tower 25 times, but received no response to those calls. The flight navigator then called Baucau Tower. A controller, who was present at Baucau aerodrome at the time, but not on operational duty, advised the flight crew that ATS was not available and that landing would be at the discretion of the flight crew. The flight navigator acknowledged the controller's advice, but did not seek information from the controller about the prevailing weather at the aerodrome. That was a missed opportunity for the flight crew to obtain updated information on the weather at Baucau. Had the flight crew sought and received that information, it may have provided them with an improved situational awareness of the prevailing weather.

During the descent in Timor-Leste airspace, none of the flight crew monitored the Timor Common High frequency of 123.45 MHz while the aircraft was above 10,000 ft (3,048 m). They also did not monitor the Timor Common Low frequency of 127.1 MHz while the aircraft was below 10,000 ft, or broadcast their intentions and traffic information on that frequency. Therefore, the flight crew had no assurance that there was no conflicting traffic. The flight crew's disregard of the requirement for traffic information broadcasts within Timor-Leste airspace increased the potential risk of an inflight collision.

The pilot in command diverted the aircraft from the published inbound track to the Baucau NDB, and descended the aircraft below the published 10 NM MSA. He continued descending the aircraft through the commencement altitude for the published non-precision instrument approach for runway 14, and through the LSALT. None of the other crewmembers commented that the pilot in command had breached those relevant safety heights.

The Baucau NOTAMs included information that instrument approach charts for Baucau were available from the Civil Aviation Division (CAD) of the Ministry of Transport, Communication and Public Works, Timor-Leste. However, the investigation determined that the flight crew used Jeppesen instrument and approach charts, and not the CAD-issued charts.

As the aircraft approached Baucau, the flight crew decided to conduct an overflight of the aerodrome before making a landing approach, and during the overflight, the flight crew realised that the runway was not where they expected it to be.

The investigation determined that the flight crew did not conduct the overflight of the aerodrome, or either of the landing approaches, with reference to the Baucau NDB. The flightcrew used selected data from their instrument approach charts for Baucau to formulate a user-defined non-precision approach using the onboard global positioning system (GPS). That user-defined procedure was a non-approved procedure. It deviated from normal practice, bypassed all the safety criteria and risk treatments inbuilt into the design of the published non-precision approach procedures, and increased the risk of a controlled flight into terrain (CFIT) accident.

The flight navigator provided the pilot in command with distance to run and lateral offset distance from the runway centreline during the overflight and the first landing approach. The flight navigator's reference to distance and lateral offset during those manoeuvres corresponded to the position of the aircraft in relation to the threshold of runway 14 as depicted on the Jeppesen charts. The navigation data provided by the flight navigator was therefore accurate in terms of where he expected the threshold of runway 14 to be, based on the Jeppesen charts. However, erroneous data on the Jeppesen charts meant that it was inaccurate in terms of where the threshold of runway 14 was actually located. The flight crew's inappropriate reliance on that data therefore increased the risk of a CFIT event.

Had the flight crew followed the non-precision runway 14 NDB approach procedure as published on either the CAD or Jeppesen charts, and not descended below the relevant MDA(H) until visual flight was assured, the position of the runway, as depicted on the Jeppesen charts would have been irrelevant. Although the runway would not have appeared where the flight crew expected it to be at the MDA(H), in visual meteorological conditions (VMC) a safe approach could have been conducted to the actual threshold of runway 14. Alternatively, if a visual approach could not be made from the relevant MDA(H), a safe missed approach could have been conducted by following the published missed approach procedures.

During the overflight and the subsequent (first) landing approach, the flight crew realised that the runway was not where they expected it to be as it was depicted on the Jeppesen charts. The pilot in command discontinued the landing approach, and the flight navigator stated that he would apply a 4 km correction to position the aircraft for a second landing approach to where he thought the runway was located. By applying the 4 km correction, the flight navigator was providing the pilot in command with inaccurate data, and resulted in the aircraft being repositioned towards a point about 1.65 km (0.88 NM) northwest of the actual position of the threshold of runway 14. That incorrect data substantially increased the hazards of the user-defined approach procedure, and the risk of a CFIT event at that stage of the flight increased to a high degree. The flight crew did not appear to identify the hazards associated with the intended improvised approach procedure, and were therefore not in a position to manage the associated risks.

As the aircraft turned on to the final approach heading during the second landing approach, the flight navigator stated that the aircraft was high on the approach profile, based on his assumption of the location of the threshold of runway 14. The pilot in command increased the rate of descent of the aircraft to about 18 m/sec (3,543 fpm), and stated 'Increased'. None of the other crewmembers commented on the high rate of descent, or drew the pilot in command's attention to the fact that the approach was unstabilised at that point. The risk ofa CFIT event is diminished by a stabilised approach, and the high descent rate in close proximity to terrain at that stage of the flight increased the risk of a CFIT event to the point where impact with terrain was almost certain. The CVR data provided no evidence that the flight crew was monitoring the increasing risk and evaluating whether to discontinue the approach to treat that risk.

The flight engineer misinterpreted the pilot in command's statement 'Increased' to be an instruction for him to increase the engine thrust, and he advanced the thrust levers. It took about 2 seconds for the pilot in command to realise that engine thrust had been increased, and he reacted by calling 'No, I increased vertical speed' and reduced the engine thrust. The flight engineer's action in increasing engine thrust was a significant distraction to the pilot in command at that stage of the flight, and probably diverted his attention from the primary task of flying the aircraft to restoring the thrust to the proper setting.

At about the same time, the aircraft descended through 162 m, which was the published MDH for a straight-in landing on the runway 14 NDB approach. Neither the pilot in command nor the copilot appeared to notice that the aircraft had descended through the MDH, and it is probable that both were distracted by the flight engineer's erroneous action. The risk ofa CFIT event is diminished if an approach is flown no lower than the published MDA(H) of an instrument approach procedure until visual flight can be assured and maintained. At that stage of the flight, descent below the MDH in instrument meteorological conditions (IMC) at a high rate of descent meant that the risk of a CFIT event had increased to an unacceptably high level and could not be treated. Impact with terrain was almost certain from that point onwards.

The high rate of descent continued unchecked until slightly less than 2 seconds before impact. It is probable that the pilot in command and the copilot were each unaware of the high rate of descent, because neither was monitoring the flight instruments while they were looking ahead of the aircraft and trying to establish visual contact with the ground.

The pilot in command applied back elevator to increase the aircraft pitch attitude in response to the copilot's urgent expression of concern that impact with terrain seemed almost certain. However, the pilot in command did not simultaneously increase the engine thrust, and it remained unchanged. Consequently, the pilot in command's attempt to avoid impact with terrain was unsuccessful because of the inertia of the aircraft and its close proximity to terrain.

The aircraft's impact with terrain was a direct consequence of the pilot in command descending the aircraft below the published minimum descent height for the runway 14 non-precision instrument approach procedure in an unstabilised manner. Furthermore, it was also as a result of poor planning by the flight crew and less than effective crew coordination. During that landing approach, the actions of the flight crew steadily increased the risk of a CFIT to an extreme level, yet they seemed unaware that the likelihood of impact with terrain was almost certain until about 2.5 seconds before it occurred.

Research conducted by an aviation industry task force, under the patronage of the International Civil Aviation Organization (ICAO), has credited the main reasons for accidents involving aeroplane hull losses to CFIT and approach-and-landing accidents. In recent years, CFIT-reduction has been the focus of organisations such as ICAO and the Flight Safety Foundation (FSF). The findings of the FSF approach-and-landing accident reduction (ALAR) task force resulted in several conclusions and recommendations, and from those, the production of the FSF ALAR Tool Kit.

This report highlights that deviations from recommended practice are a potential hazard, particularly during the approach and landing phase of flight, and increase the risk of a CFIT event. It also highlights that crew coordination is less than effective if crewmembers do not work together as an integrated team, and that support crewmembers have a duty and responsibility to ensure that the safety of a flight is not compromised by non-compliance with recommended practices.

The potentially serious to catastrophic consequences of a CFIT event remain constant, irrespective of likelihood of the event. The potential risk of CFIT can be diminished by using current technology and equipment, by implementing adequate standard operating procedures, by assessing and managing CFIT risk factors, and by developing effective crew decision-making and risk management processes.

Safety recommendations from many investigations of CFIT events and serious incidents have related to the prevention of CFIT and approach-and-landing accidents. The Australian Transport Safety Bureau (ATSB) and CAD Timor-Leste endorse those recommendations and their implementation.

This report includes a number of recommendations made by the ATSB with the intention ofenhancing the safety of flight within Timor-Leste airspace. The report also includes a recommendation by CAD Timor-Leste that ICAO publicise the safety information contained in this report.

On 1 January 2003, the crew of a Boeing 767, registered VH-OGB, operating a scheduled flight from Darwin to Singapore, reported that approximately one hour and ten minutes into the flight, and while maintaining FL380, they received an Engine Indicating and Crew Alerting System (EICAS) message indicating an autopilot and autothrottle disconnect. They reported that their attempts to re-engage the systems were unsuccessful so they reverted to manual control. Additionally, some navigation and fuel calculation functions of the Flight Management Computers (FMC) were not available. The crew elected to continue the flight and descended the aircraft to FL310 to improve manual control. They rotated cockpit duties to avoid fatigue and made an uneventful landing at Singapore.

The operator reported that an examination of the aircraft systems by engineering staff found that both elements of the dual Total Air Temperature (TAT) probe unit had failed. The TAT probe was mounted on the left side of the lower forward fuselage and consisted of dual sensors to provide system redundancy in the event of failure of one sensor. Each sensor of the TAT probe provided air temperature data to its respective Central Air Data Computer (CADC). When temperature input was lost to both CADCs, the FMC disconnected the autopilots and autothrottles, and was unable to provide some of the navigation and fuel calculation information.

The failed TAT probe was removed and sent to the component manufacturer for a detailed examination. The manufacturer of the TAT probe reported that a visual examination of the failed probe revealed damage from electrical discharge that suggested it may have been subjected to a lightning strike. The operator's records for the aircraft showed that a lightning strike on the lower left fuselage had occurred on 29 August 1999, but an inspection carried out in accordance with the aircraft manufacturer's maintenance manual, that included the TAT probe, had not revealed any evidence of lightning damage to the TAT probe.

Examination of the failed TAT probe by the manufacturer found that a dimple in the inner element tube had `popped' outwards and all four ends of the heater element leads had contacted the inner tube of the unit creating an electrical short. The manufacturer reported that water freezing in the element tube may expand and push the dimple outward. Although the visible evidence of electrical discharge had led them to conclude that failure was most likely due to a lightning strike, the reason could not be positively identified. The three years and four months that elapsed from the time of the initiating event until failure also could not be explained.

On 14 August 1998, the operator reported that a dual element failure to the TAT probe occurred to another B767 of their fleet (ATSB Occurrence number 199702646). The operator expressed concern to the aircraft manufacturer that a single, dual-element TAT probe may represent a single-point failure as both elements could become inoperative following a single event. The aircraft manufacturer advised the operator that 'The TAT probe failure described … is extremely rare on the 767'. The manufacturer considered that the dual element met certification requirements and that following failure of both TAT systems, sufficient information was available to safely continue flight under manual control.

During the investigation the operator reported another dual element failure of the TAT probe to a B767 aircraft on 28 February 2004 (ATSB Occurrence number 200400759). The operator advised that following the third dual element failure of a TAT probe and their subsequent investigations, they were implementing a functionality check of all TAT probes into the scheduled maintenance program of their B767 aircraft, and incorporating the requirements of the manufacturer's Service Letter 767-SL-34-111 dated 31 March 1998. That Service Letter suggested that operators install, at a convenient maintenance opportunity, a replacement TAT probe that offered improved performance under severe icing conditions.

The operator advised the ATSB that accounts and analysis of the Crew Resource Management (CRM) issues of both recent TAT probe failures had been drafted for publication and will be published for the education of other crews. Additionally, the operator advised that they had introduced the scenario into the CRM training discussions.

The engine manufacturer issued Service Bulletin SB72-E181 on 6 August 2003 to provide a long-term solution to the uneven blade root friction problem. That SB introduced a revised dry film lubricant (DFL) to be used as an alternate blade root lubrication coating. Incorporation of the SB is indicated by a change in blade part number.

The manufacturer has also revised the manufacturing process for the HPC blades, changing the blade root machining process from broaching to milling.

A new design HPC blade drum has been developed to prevent blade loading slot cracking. Service Bulletin SB72-E106 was issued on 7 March 2003 to include the application of the improved DFL to the first stage HPC blade root dovetails of those blade drums at manufacture.

As an interim measure, the manufacturer has revised the inspection limits for blade root damage and scores, and has instigated blade root DFL removal and replacement at each module overhaul. An ultrasonic, non-destructive-inspection procedure, that can detect blade root cracking without removing the engine from the aircraft, has also been developed.

The manufacturer reported that an update to these solutions would be supplied to all operators.