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A new ATSB report examines the effectiveness of emergency locator transmitters and reveals how pilots can increase their chances of being rescued after an aviation accident.
The investigation is continuing with a focus on the human factors issues associated with auto‑flight system mode awareness.
The Aviation Short Investigation Bulletin covers a range of the ATSB’s short investigations and highlights valuable safety lessons for pilots, operators and safety managers.
Due to reduced light, the paramedic and patient were accidentally pulled from the rock ledge as the helicopter was manoeuvred in preparation to lift them out using its winch.
Shortly after takeoff, the aircraft collided with terrain near the base of a gully and was destroyed by a post-impact fire. The pilot was fatally injured.
Soon after lifting off the pilot’s door opened and the pilot reached out to close the door. Simultaneously the helicopter abruptly pitched nose-up then steeply nose-down, rolling to the right before the right landing gear skid and main rotor blades struck the ground.
CASA advises ATSB of several safety actions taken to reduce R44 helicopter fuel tank risk.
Pilots, operators and maintainers should pay particular attention to the installation and condition of R22 drive belts and other components of the drive system.
Investigation of a fatal aircraft accident involving a Cessna 210 that occurred on 25 March 2013 near Roma, Queensland.
The train suffered a total loss of power and was unable to continue its journey.
Marine occurrence statistics provide a reminder to everyone involved in shipping that accidents, incidents, and injuries happen more often than is widely believed.
This edition highlights valuable safety lessons for pilots, operators and safety managers.
ATSB is investigating a Boeing 747 that collided with the aerobridge at Melbourne Airport. The aircraft sustained substantial damage.
Ore train 4460S travelling on the interstate main line between Port Augusta and Port Pirie collided with an eastbound motor vehicle on the Port Flinders Causeway Road level crossing.
The evidence at this stage indicates that the aircraft flew around the Borumba Dam, Imbil, and Kandanga areas for about an hour, probably mostly in or around cloud.
The aircraft severed two electrical supply cables, which were at a height of about 9 m above the ground. The flight was to attend a Christmas function at a parachute drop zone at Burrum River, near Hervey Bay, Qld.
Freight train 331 derailed near Lowdina, north of Hobart, Tasmania. Dangerous goods were involved.
The ATSB was requested by the CASA to assist in the examination of a number of aircraft flight control cable terminal fittings installed on Piper, Cessna and Beech aircraft.
In the period 2006 to 2012, the ATSB investigated three fatal accidents involving PZL-Mielec M18 Dromader aircraft. The investigations identified safety issues regarding the operation of M18 Dromader aircraft at take-off weights above 4,200kg.
The preliminary investigation report into last month’s fatal R44 helicopter accident at Bulli Tops in NSW, highlights the similarities of this accident with others involving R44 helicopters with all-aluminium fuel tanks.
This accident provides a reminder to pilots of the insidious risks associated with reduced visibility when flying in or near cloud and the benefits of leaving a Flight Note with a suitable person.
A search was commenced when the aircraft, with four persons on board failed to arrive at its planned destination. The aircraft is believed to have collided with water. The occupants sustained fatal injuries.
The investigation revealed that a combination of individual actions and systemic issues contributed to the collision. The driver’s lack of route knowledge, combined with an expectation of a clear run through the area probably influenced his failure to observe signal 135 at caution.
The ATSB team is continuing its investigation activities on-site. The team has found that the aircraft’s right wing hit a 8 metre tree before the aircraft struck the ground.
An empty coal train collided with an excavator that was being used for maintenance of rail lines near Maitland, NSW. The incident highlights the importance of ensuring the exact location of a given worksite is clearly understood by all concerned.
The ATSB’s research has identified key differences in the safety record of amateur-built aircraft when compared with similar factory built aircraft and established an important baseline on which to improve safety in this growing sector of the aviation community.
This report documents the ATSB identified safety issues and related safety actions and recommendations for the 2011–12 financial year and trends across 3 financial years.
Fatal accident a reminder that helicopter pilots need to be mindful that some confined areas will allow access, but will present significant risks on the climb out.
The ATSB has just released a new aviation bulletin containing 10 investigation reports. The Aviation Short Investigation Bulletin Issue 16 covers short, office-based investigations conducted over the past nine months.
The ATSB has commenced an investigation into this accident and an investigation team will attend the ship in Gladstone to conduct an investigation and collect relevant evidence for analysis to compile a draft investigation report.
The collision occured at a level crossing controlled by stop signs. The single occupant of the road vehicle was fatally injured.
The aircraft impacted the ground and was destroyed, the pilot was fatally injured.The ATSB has deployed three investigators, with specialisations in engineering and aircraft operations
After the engine failed, the pilot made a successful forced landing on the Birdsville Track. The ATSB's investigation highlights the importance of operators monitoring and using engine oil consumption data as a diagnostic tool.
The ATSB has recommended that Queensland Rail take action to address the safety risk associated with contaminated rail running surfaces which lead to reduced wheel/rail adhesion.
During the return of a stores container from the ship to the barge, the container came free of its slings and fell to the barge below, striking the master of the barge.
A loss of separation occurred between a Boeing 737-838 (VH-VZC) and a Boeing 737-8FE (VH-VOT) aircraft in the holding pattern at BLAKA, an IFR reporting point south-west of Brisbane, Queensland.
A broad-gauge freight train travelling on dual-gauge track was given permission to pass signal number DYN114. The route that was set took the train towards standard-gauge only track and the lead locomotive ran out of broad-gauge track, derailing both bogies.
The ATSB's latest collection of short investigations provides a summary of the less-complex factual investigation reports conducted by the ATSB and highlights important safety lessons for pilots, operators and safety managers.
A loss of separation occurred between a Boeing 717 operating a scheduled passenger service from Alice Springs to Darwin, Northern Territory, and a Boeing 737 operating a scheduled passenger service from Darwin to Melbourne, Victoria.
The ATSB encourages Bombardier pilots to take steps to reduce the risk of propeller overspeed due to ground beta selection in flight.
As part of its on-going investigation, the ATSB conducted a series of tests last night on a Queensland Rail passenger train similar to the train involved in the Cleveland station accident.
The ATSB is investigating a freight train derailed at Locksley (near Seymour) in Victoria. First information is that the last 10 of 33 wagons derailed. There were no injuries.
On 08 February 2013, a deckhand was pulled overboard and fatally crushed while attempting to reposition a fender along the side of the yacht.
The helicopter collided with terrain. The pilot sustained minor injuries and the helicopter was substantially damaged. The investigation is continuing.
Important lessons have emerged from the ATSB’s investigation into the capsize of the tug Adonis at Gladstone, Qld in June 2011.
A wave knocked a seaman off MSC Siena’s accommodation ladder while he was rigging a combination pilot ladder in preparation to embark a harbour pilot. An immediate search for the seaman was initiated by Australian search and rescue agencies but the search was unsuccessful.
The ATSB is investigating a QR passenger train that failed to stop at the Cleveland station platform and collided with the end-of-line buffer-stop, the platform and the station building.
Operators and maintainers of Rolls-Royce RB211-524 engines are alerted to the potential for wear and degradation of the intermediate-pressure turbine blade interlocking shrouds, with the possibility that this mechanism, if not detected and addressed, could lead to turbine blade cracking and loss.
Examination of the aircraft showed that its nose landing gear contacted the powerline. The powerline was located 7 m above ground level and about 140 m from the end of the 900 m long landing strip. The investigation is continuing.
The aircraft was destroyed by fire and the two people on board died as a result of the accident. The investigation is continuing and will include: examination of the engine and propeller, examination of the experience of the student and instructor, and assessment of the aircraft’s handling qualities.
Valuable safety lessons for pilots, operators and safety managers in the latest collection of ATSB’s short investigations.
The ATSB is investigating an accident involving a Cessna 172 near Wentworth, NSW on 28 May 2012. The pilot was fatally injured.
ATSB is investigating Piper PA-34-200 aircraft accident near Cable Beach, Broome, WA on 11 July 2012.
The preliminary investigation showed that the potential for any systemic issues to have contributed to the occurrence was low and that it was unlikely that any safety issues would be identified through further investigation. On that basis, the ATSB decided to discontinue its investigation.
The ATSB is urging pilots and operators to report wirestrikes and all significant aviation occurrences. Even if there's no damage to the aircraft or no injuries to people onboard the aircraft, reporting can help identify hotspots and ultimately save lives.
Freight train 1MP5 derailed on the Trans-Australian Railway Line at Goddards approximately 240 km east of Kalgoorlie in Western Australia. There were no injuries as a result of the derailment but 23 wagons derailed, and about 700 m of track required replacement.
A fire broke out in the number one cargo hold of the general cargo ship BBC Baltic while it was discharging cargo in Port Hedland. At the time, workers from Cervan Marine, a local engineering company, were gas cutting in the cargo hold using an oxy-acetylene torch.
On 5 February 2011, scheduled XPT service ST24, travelling from Melbourne to Sydney, passed Up home signal 09-6 at Henty, NSW while it was displaying a Stop (red) indication.
Issue 10 of the Aviation Short Investigation Bulletin contains 8 accident investigations. The summary reports detailed were compiled from information provided to the ATSB by individuals or organisations involved in an accident or serious incident.
Shortly after the takeoff and initial climb, the pilot most likely became disorientated due to the effects of a somatogravic illusion and placed the aircraft in a shallow decent as the aircraft accelerated, leading to a controlled flight into terrain approximately 1 km from the end of the runway.
A PZL-Mielec M18A Turbine Dromader aircraft, impacted terrain on a cotton station near Dirranbandi, Queensland while conducting a spraying flight. The pilot was fatally injured and the aircraft was destroyed by impact forces.
The aircraft wreckage of the Cessna was located west of Coonabarabran NSW. ATSB dispatched a team of three investigators to the accident site on the western side of the Warrumbungle Range. The investigation is continuing.
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.
There were 130 accidents, 121 serious incidents, and 6,823 incidents in 2011 involving VH-registered aircraft. 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.
On approach to Sydney Airport, runway 16 left, a QantasLink aircraft’s stickshaker stall warning was activated at about the final approach fix (FAF). The crew continued the approach and landed on runway 16L.
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 passage from China to Townsville, Queensland. The investigation is continuing.
On 8 January 2012, the general cargo ship ship Tycoon broke its moorings while berthed at Christmas Island and contacted the shore. The crew abandoned the ship into Royal Australian Navy ships and there were no reported injuries. The Tycoon was subsequently returned to the wharf and the ship sustained substantial damage during the incident.
This report discusses procedures that pilots can use before and during a flight to help them be absolutely sure they will have sufficient fuel to land at their destination aerodrome with reserve fuel intact.
A PZL-M18A Dromader (TPE331) aircraft impacted the ground while conducting agricultural spraying operations near Nyngan, NSW. The investigation found that the outboard 1.8 m of the right wing separated from the aircraft resulting in a loss of control and subsequent impact with the terrain. The separation of the right wing section could not be conclusively attributed to any particular factor.
A freight train (4DA2) operated by FreightLink Pty Ltd2 derailed on the Central-Australia Railway line, near Cadney Park, SA. There were no injuries but there was significant damage to rolling-stock and about 300 m of track required replacement. The investigation found that very strong winds associated with a thunderstorm were of a sufficient magnitude to initiate the rollover and subsequent derailment of a group of lightly loaded double-stacked container wagons.


