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Tonymercury Sir Nigel Gresley

Location: Botany NSW

Investigation into close call at Tullamarine

Wednesday, 22 February 2012

An investigation is underway at Melbourne Airport after a close call where two Qantas 737 jets and a small plane almost collided upon landing last week.

The Australian Transport Safety Bureau described the event as a “serious incident” as the three planes slipped passed safe separation requirements 28 kilometers from the airport, News.com reported.

According to media, the two Qantas flights were flying from Adelaide and Brisbane and were making the a descent into the airport at the safe distance when a Nomad plane started flying head-on towards one of the Qantas aircraft.

The small plane, said to be conducted an aerial survey, then turned in too close behind the other Qantas plane.

 

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

Updated Thu Feb 23, 2012 2:25pm AEDT



Training tragedy: Two experienced pilots died when an Airnorth plane crashed shortly after take-off in Darwin in March 2010.

Two experienced pilots died when an Airnorth plane crashed shortly after take-off in March 2010.

The pilots were conducting a training exercise, which included performing a simulated engine failure on take-off.

The ATSB says power was not restored to the left engine to stop the manoeuvre, leaving only a few seconds before the plane became uncontrollable.

The Embraer Brasilia aircraft crashed in bushland within the airport precinct.

The bureau says there were no systemic issues arising from the crash that would affect the future safety of aviation operations.

The report says the accident highlights the risks of in-flight engine failure training and the importance of using flight simulators for non-normal flying training and proficiency checks in larger aircraft.

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

The Australian Transport Safety Bureau says it is confident the appropriate steps are being taken to ensure a near miss between two planes at the Williamtown RAAF base near Newcastle is not repeated.

The Defence Department has now beefed up its training of air traffic controllers at the base after a Boeing 737 came too close to a Defence charter plane in February 2011.

The passenger plane had just taken off on its way to Melbourne, while the charter flight was about to land in Newcastle from Nowra.

ATSB investigators found there were a series of errors, including poor communication.

The Bureau's Chief Commissioner, Martin Dolan says the planes were being managed by separate air traffic controllers.

"And the communication wasn't as good as it could have been," he said.

"The response when it was found that the two aircraft were in conflict, or heading towards each other too much, the steps that were taken didn't immediately fix the problem so it took a while for the correct steps to be taken.

"One of the aircraft had to take some avoiding action."

Mr Dolan says Defence has since introduced oral testing and regular training on safety alerts.

"The key thing that concerned us, based on this investigation, was the amount of training that air traffic controllers has received in how to deal with a situation where you find that two aircraft might be converging on converging tracks.

"We're satisfied that the steps that Department of Defence is taking to deal with the issues we raised will make sure that something like this won't happen again."

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

The transport safety bureau has urged helicopter owners to take action in the wake of a fiery crash that killed two celebrated film-makers at Jaspers Brush last month.

Andrew Wight, 52, and 60-year-old Mike deGruy died when the Robinson R-44 chopper they were riding in hit the ground and burst into flames at an airstrip on February 4.

The fire was so intense witnesses said helpers struggled to even approach the wreckage.

In an update published this morning, the Australian Transport Safety Bureau (ATSB), which is investigating the crash, urged R-44 owners to ‘‘actively consider’’ replacing the chopper’s fuel tanks to lower the risk of fire.

‘‘[The ATSB has] issued a Safety Advisory Notice suggesting that operators and owners of R44 helicopters fitted with all-aluminium fuel tanks actively consider replacing those tanks with bladder-type fuel tanks,’’ the bureau said.

Last month, US law firm Slack & Davis said Robinson knew of a fault that included the all-aluminium fuel tanks and increased the risk of fire in the event of a crash.

In December 2010 the manufacturer introduced design modifications for new R-44s and a $6400 kit for retrofitting to existing R-44s via a "service bulletin".

It is not known publicly at this stage whether the R-44 in which Mr Wight and Mr DeGruy were killed had been retrofitted with the modifications.

The ATSB investigation remains in its early stages, and could take up to 12 months to finalise.

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

Oil leaks drip wider for A380

Wednesday, 14 March 2012

A wider pattern of oil leaks in Rolls-Royce Trent 900 engines reported by airlines was a factor in oil leak incidents suffered by the Qantas aircraft, the Australian Transport Safety Bureau (ATSB) found.

The incidents occurred with two different Qantas A380 Superjumbos on flights between Singapore and London on February 24 and November 3 last year, in which one flight was forced to divert to Dubai after crew were forced to shut down an engine after receiving a low oil pressure warning.

Initial testing found the oil leaks  were the result of a loss of clamping force in the oil feed pipe connection at the engines' casings, which then prompted "proactive safety action" taken by Rolls-Royce, Qantas and Airbus, with Qantas checking its engines' oil feed pipes more regularly for evidence of oil leakage.

A report by the ATSB identified further, more significant problems during the manufacturing process concerning higher-than-anticipated deflection loads.

“The oil feed pipe connection to the high-pressure/intermediate-pressure turbine bearing support casing was subject to deflection loads that were higher than anticipated by the engine manufacturer and the effects of those loads were not required to be considered during the engine design and testing process,” the report stated. 

Action has been taken to reduce the occurrence by the aircraft operator and engine manufacturer while a long term solution is being sort.  No organisational or systemic issues were identified during the investigation. 

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

The Australian Transport Safety Bureau is investigating a serious incident involving two passenger airliners in skies near Katherine in the Northern Territory.

The ATSB says a Qantas Boeing 737 was on its way from Darwin to Sydney last week while an Air China Airbus was flying in the same air space en route from Melbourne to Shanghai.

The safety regulator says the two planes were seen to be on converging tracks at the same flight level, resulting in a "breakdown of separation".

A spokesman for the ATSB says no further information will be released.

A similar incident involving two aircraft happened near Tennant Creek in 2009.

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

Aviation safety investigations & reports

Investigation title

Incorrect aircraft configuration - Airbus A321-231, VH-VWW, Singapore Changi International Airport, 27 May 2010

 

Investigation Number:AO-2010-035

Investigation status:Completed

Summary

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.

 

General Details

Date:

27 May 2010

Investigation Status:

Completed

Time:

1045 UTC

Investigation Type:

Occurrence Investigation

Location:

Singapore Changi International

Occurrence Type:

Aircraft Control

State:

International

Occurrence Class:

Operational

Release Date:

19 Apr 2012

Occurrence Category:

Incident

Report Status:

Final

Highest Injury Level:

None

 
Aircraft Details

Aircraft Manufacturer:

Airbus

Aircraft Model:

A321-231

Aircraft Registration:

VH-VWW

Serial Number:

3916

Operator:

Jetstar

Type of Operation:

Air Transport High Capacity

Damage to Aircraft:

Nil

Departure Point:

Darwin, NT

Destination:

Singapore

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Last update 19 April 2012

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

JETSTAR pilots forgot to put the wheels down as they came in to land at Singapore, triggering cockpit alarms, after the captain was distracted by his mobile phone.

The Australian Transport Safety Bureau launched an investigation, reconstructing the cockpit chaos from the May 27, 2010 incident on Flight JQ57, from Darwin to Singapore.

The captain, with more than 13,000 hours' flying experience, was distracted by incoming text messages on his phone. The first officer, with more than 4000 hours' experience, was probably fatigued. The pair had lost their ''situational awareness'', leading to poor decision-making and hampered communications, investigators found.

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The problems aboard JQ57 began when the co-pilot of the 220-seat Airbus saw the captain ''preoccupied with his mobile phone'', investigators said.

At 1000 feet, the co-pilot felt ''something was not quite right''. At 720 feet, a cockpit alert flashed and sounded to warn the wheels hadn't been lowered. As the captain moved to lower the undercarriage, a ''too low'' ground-warning alarm sounded as the plane descended through 500 feet, indicating the landing gear was not fully extended and locked. The co-pilot was confused by the captain's action, as he was expecting to abort the landing and reascend to the skies, investigators said.

At 392 feet, the crew aborted the landing and powered up the thrust but had lost track of their altitude, thinking they were much higher, at about 800 feet.

A further piloting error occurred, with the wrong flap setting during the ascent.

Yesterday, Jetstar said it had incorporated the lessons learned from the incident in its pilot training. ''Pilot distraction meant all the landing checklist items weren't completed before the aircraft passed an altitude of 500 feet, at which point a go-around [aborted landing] was required under our operating procedures,'' said Jetstar's chief pilot, Captain Mark Rindfleish.

''The combination of factors on JQ57 has provided new learnings and the opportunity to add to these safeguards, which we take very seriously."

These included completing landing checklists before 1000 feet and a reminder to pilots to ensure their mobiles are switched off before take-off, he said.

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

ATSB release final report into fatal helicopter crash

 

Updated 1 hour 8 minutes ago



The pilot of a helicopter is stretchered away after the crash near Cessnock last year which left two people dead.

The Australian Transport Safety Bureau says a helicopter crash that killed two men in Cessnock last year highlights the importance of thorough inspections by maintenance personnel and pilots.

The 42-year-old pilot of the Robinson R 44 helicopter survived the crash in February last year, but 52-year-old flying instructor Ivor Durham and 21-year-old passenger Sam Bateman died.

The ATSB has released its final report into the crash which found a bolt securing part of the flight control system had come loose, rendering the aircraft uncontrollable.

The ATSB says the helicopter manufacturer and the Civil Aviation Authority have since highlighted the issue to maintenance personnel.

The manufacturer has also reduced the compliance time for replacing R44 aluminium fuel tanks with ones that are more impact resistant.

The report also says the accident highlight the risks of carrying unnecessary personnel during practice flights.

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

An investigation into an iPhone that started spewing black smoke on a Regional Express (REX) flight last year has revealed the reason for the incident, and led to renewed warnings about the carriage of lithium batteries onto planes.

The iPhone that caught fire, inset with an x-ray of the loose screw inside the unit.
(Credit: REX, ATSB)

Flight crew on a trip from Lismore to Sydney last November noticed that black smoke had begun erupting from an iPhone, which had to be quickly put out with a fire extinguisher.

The phone was sent to the Australian Transport Safety Bureau (ATSB) as part of an investigation into the matter, which has now revealed that a misplaced screw punctured the battery casing, leading to a short circuit that caused the battery to overheat.

The screw that caused the issue was the result of a botched screen-replacement job from a non-authorised service centre. A screw from the bottom of the unit, adjacent to the 30-pin connector, found its way into the handset, and caused the battery compartment to puncture as a result.

No one was hurt in the incident, but it has led to the chief commissioner of the ATSB, Martin Dolan, to again warn passengers about the risks of travelling on planes with lithium battery units.

"When travelling with mobile phones, laptops and other portable electronic devices — or just their batteries — passengers should, wherever possible, carry them in the cabin, and not in checked-in baggage.

"This reinforces the Civil Aviation Safety Authority's recommendations for flying with lithium battery-powered devices," he said.

Dolan also warned against using unauthorised service agents for device repairs.

"The incident also highlights the importance of good maintenance and repair processes for these devices, and the risk of using non-authorised repair agents."

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

Australian aviation has high safety standard

Recent media reports concerning aviation safety in Australia do not reflect the high standard of aviation safety enjoyed in Australia - air travel remains one of the safest forms of travel.

Australia has an extensive mandatory reporting scheme and a healthy reporting culture that sees a broad range of occurrences (incidents and accidents) reported to the ATSB. These include reports from all sectors of the aviation sector, ranging from sport and recreational flying in ultra-lights and gyrocopters, to private flying and other general aviation operations, through to commercial passenger operations.

The vast majority of aviation safety occurrences reported to the ATSB are minor in nature. Far from 'escaping investigation', these occurrences are assessed as not requiring investigation as they are unlikely to reveal significant systemic safety issues. But it is important that the ATSB is notified of all occurrences as the data helps us to analyse trends, find patterns in transport safety and alert the relevant people to any ongoing problem or risk.

Importantly, the ATSB has not identified any change in occurrence trends that would suggest overall increasing risk or any systemic safety issues. Given the high level of flying activity on any given day, occurrences are inevitable. These can include mechanical problems, human error or environmental issues such as severe weather or birds and wildlife. Aviation systems are designed on the expectation that such issues will occur, and back-up systems or defences exist to minimise the associated risk.

The ATSB investigates to better understand why occurrences happen and to reduce the risk of them happening again. In combination with the work of the Civil Aviation Safety Authority, Airservices Australia, airlines, operators, and individual aviation professionals and practitioners, this contributes to the high standard of aviation safety that exists in Australia.

Last update 07 May 2012

 

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

Using mobile devices during flight - REPCON report



 

The ATSB recently received a confidential report from an airline passenger concerned that passengers were using their 3G mobile devices onboard a flight from Sydney to Melbourne. The report below outlines the passenger's concerns along with the ATSB's response and advice to the travelling public.

 

Report narrative:
The reporter expressed a safety concern about the use of 3G mobile devices onboard a Syd-Melb flight. The reporter, who is a regular traveller, observes that passengers are using these devices more and more frequently, texting and using internet connectivity during flight. The reporter believes that cabin crew do not take this safety matter seriously and often do not adequately warn passengers to turn off electronic devices or that the devices should be in flight mode.

Responses/received:
REPCON supplied the operator with the de-identified report. The following is a version of their response:

Cabin safety has advised that a review of our occurrence database from 01/01/11 shows that on over 500 occasions cabin crew have reported the hazard of passengers using their mobile phones and personal electronic devices (PEDs) onboard. It is felt that the sheer volume of reports received in relation to passenger non-compliance with our PED policy illustrates that cabin crew are very aware of the regulatory requirements and company policies on this matter and are very vigilant in ensuring compliance, particularly during the pre-departure preparations as the cabin is being secured for takeoff.

In addition, it's quite possible that onboard passengers writing text messages are constructing them whilst their phones are in flight mode. It is also not possible for cabin crew to manage passenger use of PEDs during takeoff and/or the descent phase as the cabin crew must be seated. The reports we receive also highlight passenger reluctance and attitudes towards PED usage and the belief it is the operator's policy and not a regulatory requirement. However, the operator honestly believes the hundreds of reports that come through each year show that our cabin crew take passenger use of PEDs at inappropriate times very seriously.

In addition, the PED policy is currently part of the cabin crew recurrent emergency procedures curriculum and is covered in the "Standard Operating Procedures" section of the training day. The proliferation of PEDs has made the potential much higher for non-compliance but it is not possible for cabin crew to check that all PEDs are switched to flight mode and then off. In this respect cabin crew act in good faith that passengers are compliant, responsible and accountable themselves.

REPCON supplied CASA with the deidentified report and a version of the operator's response. The following is a version of the response that CASA provided:

CASA has reviewed this matter with internal subject matter experts and has examined the operator's procedures, CASA is satisfied with the operator's response.


ATSB comment:
The use of mobile phones and other electronic devices is restricted as they could interfere with vital aircraft navigation systems. Current regulations give aircraft crew the power to prohibit the use of any device which can threaten the safety of an aircraft. It is very important that passengers listen to and comply with announcements from the cabin crew when these restrictions apply.

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

Avoidable Accidents



The release of Starved and Exhausted: Fuel management aviation accidents, the latest in the Avoidable Accidents series of safety booklets, has received a positive reception, with broad distribution to flying schools, aero clubs, and many aviation operators.  'We're extremely enthusiastic about this series,' says Dr Stuart Godley, the manager of the ATSB's Research Investigations and Data Analysis. 'It's designed to be an accessible and useful safety resource, and we're happy that the booklets are being read by pilots and instructors.'

The Avoidable Accidents booklets each focus on a type of accident. 'We're looking at very specific types of accidents for these publications,' explains Dr Godley. 'These are accidents which happen, not because of some random occurrence, but because of individual actions. We're not saying that these accidents took place because of recklessness or incompetence, far from it. They're decisions, planning and preparation, risk taking, and sometimes actions or inactions that don't automatically stand out as dangerous, that one might take for granted, but which have resulted in accidents. Becoming aware of how such behaviours have led to accidents will hopefully guard you against making the same mistakes. It's very much a case of "forewarned is forearmed".'

The ATSB receives thousands of notifications every year. Although only some of the occurrences get formally investigated, all of the information is retained in the ATSB's database, drawing a vast and detailed portrait of aviation safety in Australia. Inevitably, patterns emerge. 'We have an ongoing program of monitoring trends,' explains Godley, 'and we identify the accidents which keep repeating themselves. These are the perfect topics for this series.'

Each booklet is short, and to the point, and focused on giving readers useful information. It includes case studies describing how different pilots, of all ranges of experience, have, through different routes, ended up in the same types of accidents. 'When hearing about an individual accident, some pilots have the impulse to say "oh, they ran out of fuel, well, that's dangerous, I won't do that",' says Dr Godley, 'but there are many different ways that these problems can arise, and it's not always a case of the obvious mistake.' The booklets describe the various chains of events that have led to accidents, and then gives ways that pilots can avoid suffering these accidents. 'In these booklets, it's not just describing accidents. Every accident has a lesson, and these lessons learned are drawn out to help other pilots.'
And how long will the series be? How many booklets will the ATSB produce?

'It's an ongoing series,' says Dr Godley. 'We'll keep expanding it until we run out of topics. These are timeless publications, focussing on problems that have been recurring for a long time. Hitting wires, flying into cloud, these are accidents that have been happening for 90 years, practically since the beginning of aviation, and they're accidents that pilots can prevent from happening. No matter how good the training and how advanced the aircraft, people keep having the same accidents. They have been called 'avoidable accidents' because they are accidents that didn't have to happen. As a pilot, you have a lot of control of making sure they don't happen to you.'

'These booklets would be useful to any pilot, from a first-time student in a flying school to an experienced pilot who's flying professionally. We're eager to share them. We think they're a valuable resource, that is free.'

The Avoidable Accident series is available online via the ATSB website, alternativly the ATSB will gladly provide free copies of the Avoidable Accidents series to anyone who would like them. Please send requests via email to atsbinfo@atsb.gov.au or telephone 1800 020 616 for further informaion.

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

Updated: 23 May 2012

On 1 May 2012, the pilot of a Piper PA25-235/A9 'Pawnee' aircraft, registered VH-GWS, was conducting agricultural operations near Hallston, Victoria. The aircraft departed nearby Leongatha Airport and flew to a local airstrip near Hallston, where approximately 350 to 400kg of superphosphate (fertilizer) was loaded for the first run of the day.

At around 0920, the aircraft took off from the airstrip and witnesses observed it passing low overhead, before turning through about 270 degrees to the left and descending into a gully, where it released some of the fertilizer load. Immediately after this, the aircraft was observed rocking side to side (about the roll-axis) before passing out of view and colliding with terrain near the base of the gully. The aircraft was destroyed by a post-impact fire and the pilot, who was the sole occupant, sustained fatal injuries.

The investigation is continuing and will include:

  • analysis of the accident and impact sequence
  • a review of the pilot's experience, training and medical records
  • a review of the aircraft's maintenance documentation
  • a study of the local weather conditions

 The investigation is expected to be completed by February 2013.

_____________

The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update.

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

A helicopter pilot who was involved in a crash east of Katherine has pleaded guilty to transporting dangerous goods and providing a misleading accident report to the Australian Transport Safety Bureau.

Darwin Magistrates Court has heard 41-year-old Mark Sullivan strapped a power generator filled with fuel into an empty passenger seat of the helicopter and failed to comply with a number of procedures outlined in an operations manual.

Sullivan was flying two Roper Gulf Shire employees to the remote Northern Territory community of Numbulwar in Arnhem Land to deliver emergency cyclone supplies in March 2010.

The chopper crashed at Flying Fox Creek Station before getting to its destination.

The court was told the generator landed on one of the passengers, leaking fuel into his eyes and mouth.

The other passenger blacked out on impact.

None of those involved in the crash were badly injured.

At the time, police charged Sullivan with six offences.

Today, three charges were withdrawn by the prosecution and Sullivan pleaded guilty to the other three charges.

Sullivan was sentenced to a three-month suspended jail term and fined $9,000.

His pilot's licence was suspended for 12 months.

In sentencing, Magistrate Greg Cavanagh told the court that Sullivan's actions were "blatantly outrageous and seriously dangerous".

Mr Cavanagh said he believed providing misleading information to the Australian Transport Safety Bureau was the most "reprehensible" charge.

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW


The Australian Transport Safety Bureau (ATSB) is seeking applications for the following vacancies:

• Senior Transport Safety Investigator - Helicopter Pilot
Brisbane office
Interested candidates must have relevant qualifications and experience in commercial helicopter operations.


• Senior Transport Safety Investigator - Marine
Brisbane or Perth office
Interested candidates must have relevant qualifications as a Master Mariner or Chief Engineer and hold a Class 1 Certificate, and/or seagoing experience in a senior management position.


NOTE: ATSB jobs are only open to Australian citizens.

Click the Apply Now buttom to go the the employment opportunities page.

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

Marine safety investigations & reports

Investigation title

Main engine beakdown and disabling of the Hong Kong registered bulk carrier ID Integrity in the Coral Sea, off Queensland on 17 May 2012

 

Investigation Number:295-MO-2012-005

Investigation status:Active

Summary

At 1218 on 17 May 2012, about 600 kilometres NE from Cairns, the bulk carrier ID Integrity suffered a main engine breakdown in the Coral Sea while it was on pasage from China to Townsville, Queensland. The crew could not repair the main engine and the ship drifted in a westerly direction towards the Great Barrier Reef.

On 19 May, Australian tugs were despatched to assist the disabled ship as it drifted closer towards the outer edge of the Great Barrier Reef. On 20 May, the Australian Maritime Safety Authority's tug Pacific Responder had ID Integrity under tow with another two tugs  in attendance. The ship was towed to Cairns, where it was anchored at 1400 on 23 May for inspection and repairs.

The ATSB initiated an investigation into the incident on 21 May and despatched two investigators to attend the ship. The investigators attended the ship at Cairns and collected information for the ATSB safety investigation. When a draft investigation report is prepared, it will be forwarded to directly involved parties for comment.

A report has not yet been released for this investigation.

 

General Details

Date:

17 May 2012

Investigation Status:

Active

Time:

1218 (UTC+10)

Investigation Type:

Occurrence Investigation

Location:

Coral Sea, 600 kilometres NE from Cairns. 13º 13S, 149º 34E

Occurrence Type:

Disabled

State:

QLD

 

 

 

 

Occurrence Category:

Serious Incident

Report Status:

Pending

Highest Injury Level:

None

 
Vessel Details

Vessel:

ID Integrity

Flag:

Hong Kong

IMO:

9132923

Type of Operation:

Bulk Carrier

Damage to Vessel:

Minor

Departure Point:

Shanghai, China

Departure Time:

5 May 2012

Destination:

Townsville

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Last update 25 May 2012

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

Aviation safety investigations & reports

Investigation title

Stall warning device event - Bombardier Inc DHC-8-315, VH-TQL, Sydney Airport, NSW, 1 March 2011

 

Investigation Number:AO-2011-036

Investigation status:Completed

Summary

On 1 March 2011, a QantasLink Bombardier Inc DHC-8-315, registered VH-TQL, was conducting a regular public transport flight from Tamworth Airport to Sydney Airport, New South Wales. The crew were conducting a Sydney runway 16 left (16L) area navigation global navigation satellite system (RNAV(GNSS)) approach in Vertical Speed (VS) mode. The aircraft's stickshaker stall warning was activated at about the final approach fix (FAF). The crew continued the approach and landed on runway 16L.

The stickshaker activated at a speed 10 kts higher than was normal for the conditions. The stall warning system had computed a potential stall on the incorrect basis that the aircraft was in icing conditions. The use of VS mode, as part of a line training exercise for the first officer, meant that the crew had to make various changes to the aircraft's rate of descent to maintain a normal approach profile.

On a number of occasions during the approach the autopilot pitched the aircraft nose up to capture an assigned altitude set by the pilot flying. The last recorded altitude capture occurred at about the FAF, which coincided with the aircraft not being configured, the propeller control levers being at maximum RPM, and the power levers at a low power setting. This resulted in a continued speed reduction in the lead-up to the stickshaker activation.

Each factor that contributed to the occurrence resulted from individual actions or was specific to the occurrence. The Australian Transport Safety Bureau is satisfied that none of these safety factors indicate a need for systemic action to change existing risk controls. Nevertheless, the operator undertook a number of safety actions to minimise the risk of a recurrence.

In addition, the occurrence highlights the importance of effective crew resource management and of the option of conducting a go-around should there be any doubt as to the safety of the aircraft. Transport Canada, which regulates the aircraft manufacturer, advised that it will publish a summary of this occurrence and recommend that operators consider using it in their scenario-based crew resource management training programs.

 

General Details

Date:

01 Mar 2011

Investigation Status:

Completed

Time:

1810 EDT

Investigation Type:

Occurrence Investigation

Location:

Sydney Airport

Occurrence Type:

Miscellaneous

State:

NSW

Occurrence Class:

Operational

Release Date:

28 May 2012

Occurrence Category:

Incident

Report Status:

Final

Highest Injury Level:

None

 
Aircraft Details

Aircraft Manufacturer:

Bombardier

Aircraft Model:

DHC-8-315

Aircraft Registration:

VH-TQL

Serial Number:

603

Operator:

QantasLink

Type of Operation:

Air Transport High Capacity

Damage to Aircraft:

Nil

Departure Point:

Tamworth, NSW

Destination:

Sydney, NSW

Download Final Report
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Last update 28 May 2012

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

AN INVESTIGATION into why a QantasLink Dash-8’s warning system showed crew members the aircraft was in “icing conditions” while travelling between Tamworth and Sydney in March last year has concluded.

A report, released by the Australian Transport Safety Bureau, said the plane left Tamworth Airport on March 1, 2011, and its stickshaker activated at a speed 10 knots higher than normal for conditions.

The report said the aircraft’s stall-warning

system incorrectly computed the engine stalling on the basis the plane was “icing”.

As a result, the crew had to make various changes to the aircraft’s descent into Sydney, to maintain a normal approach to the runway.

“On a number of occasions during the approach, the autopilot pitched the aircraft nose up, to capture an assigned altitude sat by the pilot flying. The operator undertook a number of safety actions to minimise the risk of reoccurrence,” the report said.

The report suggested the actions of the crew be commended and that an outline of what they did be used in future

scenario-based crew resource-management training programs.




 

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

Aviation Occurrence Statistics 2002 to 2011

Summary

Why we have done this report
Thousands of safety occurrences involving Australian-registered and foreign aircraft are reported to the ATSB every year by individuals and organisations in Australia's aviation industry, and by the public. The aim of the ATSB's statistical report series is to give information back to pilots, operators, regulators, and other aviation industry participants on what accidents and incidents have happened, how often they are happening, and what we can learn from them.

What the ATSB found
There were 130 accidents, 121 serious incidents, and 6,823 incidents in 2011 involving VH-registered aircraft. These included a first officer who was thrown off a set of portable stairs by jet blast from a Boeing 747 at Brisbane Airport, a freight flight that disappeared while trying to land in the Torres Strait Islands, a Boeing 777 that flew just 1,000 feet above suburban Melbourne while on approach to land, and an ABC helicopter that was tragically lost on a flight over Lake Eyre.

General aviation operations continue to have an accident rate higher than for commercial air transport operations: in 2011, about four times higher for accidents, and nine times higher for fatal accidents.

Most commercial air transport accidents and serious incidents were related to reduced aircraft separation, and engine issues. Charter operations accounted for most of the accidents, including two fatal accidents in 2011. Air transport incidents were more likely to involve birdstrikes or a failure to comply with air traffic control instructions or published information.

For general aviation aircraft, accidents and serious incidents often involved terrain collisions, aircraft separation issues, or aircraft control problems. Where general aviation aircraft were involved in an incident, airspace incursions, failure to comply with air traffic control, and wildlife strikes were common.

In most operation types, helicopters had a higher rate of accidents and fatal accidents than aeroplanes, except for in charter operations. Even though the fatal accident rate is generally higher, helicopter accidents are on the whole associated with fewer fatalities than fixed-wing aircraft.

Safety message
Aviation occurrence statistics provide a reminder to everyone involved in the operation of aircraft that accidents, incidents, and injuries happen more often than is widely believed. Some of the most frequent accident types are preventable, particularly in general aviation. Pilots and operators should use the misfortunes of others to help identify the safety risks in their operation that could lead to a similar accident or serious incident.

Timely and thorough reporting of safety incidents is paramount. The growth of reporting to the ATSB that has been seen over the last 10 years has helped us to better understand why accidents and incidents happen, and what the major safety risks are in different types of aviation operations. This helps everyone in the aviation industry to better manage their safety risk.

Type:

Statistical Publication

Investigation Number:

AR-2012-025

Publication Date:

29/05/2012

ISBN:

978-1-74251-268-8

Last update 29 May 2012

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

Aviation safety investigations & reports

Investigation title

Collision with terrain - Cessna Aircraft 172, VH-WLF, 10 Km West of Wentworth airfield NSW, 28 May 2012

 

Investigation Number:AO-2012-072

Investigation status:Active

Summary

Around 1740 EST on 30 May 2012, the ATSB was notified that the wreckage of the missing Cessna 172 that had departed Wentworth, New South Wales on Monday, had been located by searchers a few kilometres to the south west of the Wentworth air field. The pilot was fatally injured.

The ATSB has commenced an investigation and deployed three investigators from the Canberra and Brisbane offices. The investigators expect to arrive at Wentworth around midday on 31 May.

The investigators will commence an examination of the accident site during the afternoon of Thursday 31 May and are expected to be on site for two days. Investigators will also interview witnesses and gather various operational and maintenance documentation.

 

General Details

Date:

28 May 2012

Investigation Status:

Active

Time:

10:00 EST

Investigation Type:

Occurrence Investigation

Location:

10 Km West of Wentworth airfield

Occurrence Type:

Terrain Collision

State:

NSW

 

 

 

 

Occurrence Category:

Accident

Report Status:

Pending

Highest Injury Level:

Fatal

 
Aircraft Details

Aircraft Manufacturer:

Cessna

Aircraft Model:

172

Aircraft Registration:

VH-WLF

Serial Number:

29217

Departure Point:

Wentworth, NSW

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Last update 31 May 2012

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

Australian aviation wildlife strike statistics: Bird and animal strikes 2002 to 2011

Summary

Why we have done this report
A significant proportion of all occurrences reported to the Australian Transport Safety Bureau (ATSB) involve aircraft striking wildlife, especially birds. The aim of the ATSB's statistical report series is to give information back to pilots, aerodrome and airline operators, regulators, and other aviation industry participants to assist them with controlling the risks associated with bird and animal strikes. This report updates the first edition published in 2010 with data from 2010-2011.

What the ATSB found
In 2011, there were 1,751 birdstrikes reported to the ATSB. Most birdstrikes involved high capacity air transport aircraft. For high capacity aircraft operations, reported birdstrikes have increased from 400 to 980 over the last 10 years of study, and the rate per aircraft movement also increased. Domestic high capacity aircraft (such as Boeing 737 and Airbus A320) were those most often involved in birdstrikes, and the strike rate per aircraft movement for these aircraft was significantly higher than all other categories. Larger high capacity aircraft (such as Boeing 747 and Airbus A340 and A380) had a significantly lower strike rate. One in eight birdstrikes for turbofan aircraft involved an engine ingestion.

Takeoff and landing was the most common part of a flight for birdstrikes to occur in aeroplanes, while helicopters sustained strikes mostly while parked on the ground, or during cruise and approach to land. Birdstrikes were most common between 7:30 am and 10:30 am each morning, with a smaller peak in birdstrikes between 6pm and 8pm at night, especially for bats.

All major airports except Hobart and Darwin had high birdstrike rates per aircraft movement in the past 2 years compared with the average for the decade. Avalon Airport had a relatively small number of birdstrikes, but along with Alice Springs, had the largest strike rates per aircraft movement for all towered aerodromes in the past 2 years.

In 2010 and 2011, the most common types of birds struck by aircraft were bats/flying foxes, galahs, kites and lapwings/plovers. Galahs were more commonly involved in strikes of multiple birds. Not surprisingly, larger birds were more likely to result in aircraft damage.

Animal strikes were relatively rare. The most common animals involved were hares and rabbits, kangaroos and wallabies, and dogs and foxes. Damaging strikes mostly involved kangaroos, wallabies and livestock.

Safety message
Australian aviation wildlife strike statistics provide a reminder to everyone involved in the operation of aircraft and aerodromes to be aware of the hazards posed to aircraft by birds and non-flying animals. While it is uncommon that a birdstrike causes any harm to aircraft crew and passengers, many result in damage to aircraft, and some have resulted in serious consequential events, such as forced landings and high speed rejected takeoffs.

Timely and thorough reporting of birdstrikes is paramount. The growth of reporting to the ATSB that has been seen over the last 10 years has helped to better understand the nature of birdstrikes, and what and where the major safety risks lie. This helps everyone in the aviation industry to better manage their safety risk.

Type:

Research and Analysis Report

Investigation Number:

AR-2012-031

Publication Date:

04/06/2012

ISBN:

978-1-74251-265-5

Last update 04 June 2012

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

Collsion with terrain - Cessna 182Q, VH-CWQ, near Coonabarabran, NSW, 4 June 2012

 

Investigation Number:AO-2012-076

Investigation status:Active

Summary

On Monday, the ATSB was kept informed by AMSA of progress in the search for the missing aircraft. Once advised, in the afternoon, that the wreckage had been located the ATSB commenced an investigation. A team of three investigators will travel via Dubbo to the accident site on the western side of the Warrumbungle Range today.

The investigation is continuing.

 

General Details

Date:

04 Jun 2012

Investigation Status:

Active

Time:

1200 EST

Investigation Type:

Occurrence Investigation

Location:

38 km West Coonabarabran

Occurrence Type:

Terrain Collision

State:

NSW

Occurrence Class:

Operational

 

 

Occurrence Category:

Accident

Report Status:

Pending

Highest Injury Level:

Fatal

 
Aircraft Details

Aircraft Manufacturer:

Cessna

Aircraft Model:

182Q

Aircraft Registration:

VH-CWQ

Serial Number:

18267031

Type of Operation:

Private

Damage to Aircraft:

Serious

Departure Point:

Walgett, NSW

Destination:

Mudgee, NSW

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Last update 05 June 2012

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

Today marks 30 years of independent safety investigations in Australia.

On this day in 1982, the Bureau of Air Safety Investigation (BASI) was created as an operationally independent agency.

Now operating as the Australian Transport Safety Bureau (ATSB), Australia's national transport safety investigator has a hard-earned reputation for professionalism, independence and technical expertise, both at home and abroad.

The ATSB's role was expanded in 1999 to include rail and marine accident investigations.

Over the last three decades, this has led to more than 4,000 transport safety investigations.

Just three years ago, this Federal Labor Government established the ATSB as a separate statutory agency with a full time Chief Commissioner and two part time Commissioners.

In addition, from 18 December 2012, the ATSB will become the main national investigator for rail accidents and incidents, working alongside the new National Rail Safety Regulator, replacing seven state and territory rail safety agencies.

This expanded role has been made possible as part of the Government's broader transport reform program to create single national transport regulators.

Whether investigating aviation, marine or rail incidents and accidents, the ATSB's underlying goal has been to promote safer transport for Australians.

Australia has a proud safety record. Ongoing vigilance by our safety agencies is critical to maintaining and building on that record.

I congratulate the ATSB, its commissioners and staff past and present on this achievement.

For more information: visit http://www.atsb.gov.au for a copy of the Past Present Future publication which celebrates the history of transport safety investigations in Australia.

 

 
Tonymercury Sir Nigel Gresley

Location: Botany NSW

Aviation safety investigations & reports

Investigation title

Collision with terrain - PZL-Mielec M18A Turbine Dromader, VH-FOZ, 23 km WSW of Dirranbandi, Qld, 19 July 2011

 

Investigation Number:AO-2011-082

Investigation status:Completed

Summary

What happened
At 1157 on 19 July 2011, a PZL-Mielec M18A Turbine Dromader aircraft, registered VH-FOZ, impacted terrain on a cotton station about 23 km west-south-west of Dirranbandi, Queensland while conducting a spraying flight. The pilot was fatally injured and the aircraft was destroyed by impact forces.

What the ATSB found
The ATSB found that, for reasons that could not be determined with certainty, the aircraft departed from controlled flight during a turn at low altitude and the pilot was unable to recover before impacting the ground.

The ATSB also identified a significant safety issue affecting the safety of future spraying operations in turbine Dromader aircraft: the potential for the aircraft's centre of gravity to vary significantly depending on the weight in the aircraft's chemical/spray tank and exceed the forward and aft limits during a flight. This safety issue was unlikely to have contributed to the accident as the aircraft was probably within the approved weight and balance limits at the time of the accident.

Moreover, although also not found to have contributed to the accident, there was an increased risk to the flight from the aircraft's operation, at times, in excess of its published airspeed and angle of bank limitations.

What has been done as a result
During the investigation, the Australian Transport Safety Bureau worked with the Civil Aviation Safety Authority (CASA) and the Aerial Agricultural Association of Australia to address the risk to turbine Dromader aircraft of the potential for excessive movement of the aircraft's centre of gravity as the contents of the aircraft's chemical/spray tank are dumped or dispensed.

CASA and the owner/developer of the approval for operations at weights of up to 6,600 kg, which had effect during the flight, took action to improve operator and pilot understanding of the issue. In addition, the owner/developer indicated that the design would be reviewed to address any excessive centre of gravity variations.

Safety message
Although it was not contributory in this instance, the ATSB highlights the importance of pilots maintaining their aircraft's weight and balance within limits throughout a flight, and of understanding the implications of changing weight and balance. Similarly, the ATSB reaffirms the importance of being familiar with and adhering to aircraft operational limitations.

 

General Details

Date:

19 Jul 2011

Investigation Status:

Completed

Time:

1157 EST

Investigation Type:

Occurrence Investigation

Location:

23 km WSW of Dirranbandi

Occurrence Type:

Terrain Collision

State:

QLD

Occurrence Class:

Operational

Release Date:

08 Jun 2012

Occurrence Category:

Accident

Report Status:

Final

Highest Injury Level:

Fatal

 
Aircraft Details

Aircraft Manufacturer:

PZL Warszawa-Okecie

Aircraft Model:

M18A Turbine Dromader

Aircraft Registration:

VH-FOZ

Serial Number:

1Z014-10

Type of Operation:

Aerial Work

Damage to Aircraft:

Destroyed

Download Final Report
[PDF: 2.04MB]

 

 

Alternate: [DOC: 6.79MB]

Download Preliminary Report
[PDF: 196KB]

 

 

Alternate: [DOC: 1.4MB]

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Last update 08 June 2012

 

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