Significant safety investigations

This section of the Annual Report fulfils section 63A of the Transport Safety Investigation Act 2003, which requires the Chief Commissioner to report investigations to the Minister that were conducted during the financial year and raise significant issues about safety.

Aviation investigations

Landing below minima due to fog involving Boeing 737s, registered VH-YIR and VH-VYK, at Mildura Airport,
Victoria on 18 June 2013 (AO-2013-100) website Links

On 18 June 2013, two Boeing 737 aircraft were on scheduled flights to Adelaide, South Australia—VH-YIR operated by Virgin Australia Airlines Pty Ltd as Velocity 1384 and VH-VYK operated by Qantas Airways Ltd as Qantas 735. On nearing Adelaide, the forecast improvement in weather conditions had not occurred. As a result, both aircraft diverted to Mildura. On arrival at Mildura, the actual weather conditions were significantly different to those forecast, in particular visibility reduced by fog. Both flight crews conducted an instrument approach and landed below minima. The flight crew of Velocity 1384 landed with fuel below the fixed reserve.

The ATSB found that the weather deterioration at Adelaide had not appeared on the forecast when both aircraft departed their respective ports. Furthermore, the forecast duration of the fog in the subsequent, amended, forecast showed a clearance time which was earlier than actually occurred. This meant that Qantas 735 continued to Adelaide with the expectation that the fog would clear prior to its arrival—this did not occur. These forecasts also influenced the decision-making of the Virgin flight watch personnel, who did not pass the weather information on to the flight crew of Velocity 1384.

Regarding the weather at Mildura, the ATSB found that the deterioration was significantly worse than originally forecast. This resulted in the need for both flights to land in conditions that were below minima. The ATSB identified that both flight crew uploaded sufficient fuel for the originally-forecast conditions, in accordance with their operators' fuel policy and the Civil Aviation Safety Authority's (CASA) requirements.

The ATSB also found that in certain weather patterns and at certain locations, fog is both rare and difficult to forecast reliably.

In addition, the ATSB noted that the industry expectation for the provision of flight information services was not aligned with that provided by Airservices Australia. It was identified that, in certain circumstances, pilots would not be made aware of a deterioration in the weather at airports equipped with an Automatic Weather Information Service or other Automatic Broadcast Service. These services do not provide for the recognition and active dissemination of special weather reports (SPECI) to pilots, therefore do not meet the intent of the SPECI alerting function provided by controller-initiated flight information service.

As a result of this investigation, the ATSB issued a safety recommendation to Airservices Australia that they work in collaboration with the Bureau of Meteorology in order to instigate a system change that will reinstate the alerting function of SPECI reports—which are currently unavailable through an automatic broadcast service.

The ATSB's investigation report (AO-2013-100) is available from the ATSB website at

In-flight break-up involving PZL Mielec M18A Dromader, registered VH-TZJ, 37 km west of Ulladulla,
New South Wales on 24 October 2013 (AO-2013-187) website Links

This accident confirmed that even when flying within operational limits, the 'harder' and faster an aircraft is flown, the more rapidly the structure will fatigue. Also highlighted was the importance of using properly-approved maintenance instructions and referring to them when conducting maintenance.

On 24 October 2013, the pilot of a modified PZL Mielec M18A Dromader, registered VH-TZJ, was conducting a firebombing mission about 37 km west of Ulladulla, New South Wales. On approach to the target point, the left wing separated. The aircraft immediately rolled left and descended, impacting terrain. The aircraft was destroyed and the pilot was fatally injured.

The ATSB found that the left wing separated because it had been weakened by a fatigue crack in the lower attachment fitting. The fatigue crack originated at small corrosion pits in the attachment fitting. These pits formed stress concentrations that accelerated the initiation of fatigue cracks.

Figure 7: Outer section of left wing of VH-TZJ

Outer section of left wing of VH-TZJ

Source: ATSB

The ATSB also found that although the aircraft manufacturer's instructions required the corrosion pits to be removed, they were not completely removed during previous maintenance. During maintenance, the wing fittings were inspected using an eddy current inspection method. This inspection method was not approved for that particular inspection and may not have been effective in detecting the crack.

Data from a series of previous flights indicated that the manner in which the aircraft was flown during its life probably accelerated the initiation and growth of the fatigue crack.

Finally, the ATSB also found a number of other factors which, although they did not contribute to the accident, had the potential to reduce the safety of operation of PZL M18 and other aircraft. These included the incorrect calculation of the flight time of M18 aircraft and a lack of robust procedures for approving non-destructive inspection procedures.

As a result of this accident, CASA revised the airworthiness directive for inspection of wing attachment fittings, to ensure that they were inspected using the magnetic particle inspection method. CASA also made, or plans to make, a number of changes to their systems and procedures to address issues identified by the ATSB's investigation.

Separately, the ATSB reminded M18 aircraft operators of the importance of the correct application of service life factors when operating at weights above the original maximum take-off weight. PZL Mielec indicated it would release additional maintenance documentation clarifying the need for removal of the wings for proper inspection of the wing attachment fittings. Finally, at the request of the owner, the supplemental type certificate for operation of the modified M18 Dromader at take-off weights up to 6,600 kg was suspended by CASA.

The ATSB's investigation report (AO-2013-187) is available from the ATSB website at

In-flight break-up involving de Havilland DH82A Tiger Moth, registered VH-TSG, 300 m east of South Stradbroke
Island, Queensland on 16 December 2013 (AO-2013-226) website Links

The in-flight break-up of DH82A Tiger Moth near South Stradbroke Island, Queensland, emphasises the need to fully consider the service history of a part when redesigning and manufacturing parts critical to the structural integrity of the aircraft. It also shows the importance of the regulator's role in ensuring that parts approved under an Australian Parts Manufacturer Approval (APMA) are fully considered and comply with design requirements. Further, in the context of maintenance, this in-flight break-up shows the importance of utilising genuine or approved substitute aircraft parts that are suitable for purpose—especially in sections of the aircraft that are critical to flight.

This accident also highlights how important it is for commercial vintage aircraft operators to consider the risks associated with aircraft age and to understand the originally intended use of the design before commencing their operations.

On 16 December 2013, at about 1215 EST, a de Havilland DH82A (Tiger Moth) aircraft took off on a commercial joy flight, in the Gold Coast area, from the operator's airstrip at Pimpama. A pilot and passenger were on board. At about 1224, one minute after the pilot commenced aerobatics, the left wings failed and the aircraft descended steeply impacting the water. The aircraft was destroyed and the two occupants were fatally injured.

The ATSB found that both of the aircraft's fuselage lateral tie rods, which assist in transferring flight loads through the fuselage, had fractured. The location of the fracture coincided with areas of pre-existing fatigue cracking in the threaded sections of the rods, near the join with the left wing. The tie rods fractured during an aerobatic manoeuvre, resulting in the left lower wing separating from the aircraft and the subsequent in-flight break-up. The ATSB also found that the tie rods were aftermarket-parts manufactured under an APMA. Safety issues were identified in the tie rods' design and manufacture, as well as in the supporting regulatory approval processes. Safety issues were also identified in the maintenance and operation of the aircraft.

Figure 8: VH-TSG wreckage reconstruction

VH-TSG wreckage reconstruction

Source: ATSB

The ATSB consulted with the Type Design Organisation, as well as regulators and investigation authorities from Australia, New Zealand and the United Kingdom, about the failure of the APMA tie rods. A failure that occurred well before the published retirement life for Tiger Moth tie rods. In response, the United Kingdom Civil Aviation Authority issued an airworthiness directive on 21 March 2014, that mandated the removal from service of all tie rods produced by the same Australian manufacturer. The airworthiness directive was subsequently also mandated by CASA and the New Zealand Civil Aviation Authority. Significant additional safety action is being carried out by the Type Design Organisation to further enhance the safety of all Tiger Moth operations.

In addition, the ATSB issued a safety recommendation to CASA to take action to provide assurance that over a thousand other parts, approved for APMA at about the same time as the tie rods, were appropriately considered before approval.

The ATSB's investigation report (AO-2013-226) is available from the ATSB website at

Accredited Representative to the Dutch Safety Board investigation into the loss of Malaysia Airlines
Boeing 777-200, registered 9M-MRD, near Hrabove, eastern Ukraine on 17 July 2014 (AE-2014-130) website Links

On 17 July 2014, a Malaysia Airlines Boeing 777-200, registered 9M-MRD, en route from Amsterdam in the Netherlands to Kuala Lumpur, Malaysia, disappeared from air traffic services radar overhead the eastern Ukraine. Aircraft wreckage was identified over a large area to the south and west of the village of Hrabove, eastern Ukraine. There were no survivors.

As the occurrence took place in the Ukraine, the National Bureau of Air Accident Investigation of Ukraine (NBAAI) commenced an accident investigation, under Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation, on 17 July 2014. As part of its investigation, the NBAAI requested assistance from the ATSB and, under clause 5.23 of Annex 13, the ATSB appointed an accredited representative and an adviser to the NBAAI investigation. In addition, an external investigation was initiated under the provisions of the Australian Transport Safety Investigation Act 2003.

The ATSB investigators departed for Kiev, Ukraine, on 21 July 2014 to participate in the NBAAI accident investigation. Subsequently, on 23 July 2014, the Ukrainian Government delegated the conduct of the investigation to the Dutch Safety Board (DSB), under clause 5.1 of Annex 13. The ATSB investigators remained in Kiev to assist the Dutch investigation before relocating with the investigation team to the DSB headquarters in the Netherlands on 1 August 2014. The ATSB investigators returned to Australia on 8 August 2014.

During the investigation, the ATSB and other accredited representatives contributed to the development of the DSB's preliminary investigation report, which was released to the public on 9 September 2014. In addition, the ATSB representative attended two investigation progress meetings in the Netherlands. The second of these meetings included an examination of the reconstruction of the aircraft from recovered wreckage, items and components.

Subsequently, and consistent with Annex 13 standards and recommended practices, the ATSB and other accredited representatives received a copy of the draft investigation report for comment. The DSB considered these, and comments from other relevant parties to the investigation, before finalising their report.

The DSB completed its investigation and, in accordance with the provisions of Annex 13, the final investigation report was published on 13 October 2015. This report, together with information on the investigation, is available from the DSB's website at

Marine investigations

The two marine safety investigations described below identify the broad safety concerns related to marine work practices, an ATSB SafetyWatch priority. Both investigations also highlight the importance of emergency response capability in Australian ports.

Engine room fire on board Marigold, Port Hedland, Western Australia on 13 July 2014
(312-MO-2014-008) website Links

On 13 July 2014, a fire started in the engine room of the bulk carrier Marigold, while it was loading a cargo of iron ore in Port Hedland, Western Australia.

While fighting the fire, the ship's crew activated the Halon gas fixed fire suppression system for the engine room. However, a full release of Halon gas did not occur, nor was the engine room effectively sealed. Consequently, the fire continued for about 12 hours until it burnt itself out.

The ATSB determined that the source of the fire was Marigold's number one generator, where a fuel oil pipe fitting had failed. The resulting spray of fuel oil likely contacted the hot surface of the generator and ignited.

Failures within the Halon system, and multiple failures of the ventilation closing mechanisms, were indicative of a lack of effective planned maintenance on board.

The port's emergency response plan was initiated, but there were misunderstandings between the agencies involved as to their roles during the initial stages of the incident and response. Their emergency plans did not refer to trigger points for transfer of control, nor did it include detailed instructions on how to hand over control during an incident.

Figure 9: A harbour tug assisting the firefighting efforts

A harbour tug assisting the firefighting efforts

Source: Port Hedland Pilots

As a result of this fire, and another shipboard fire in Fremantle, Western Australia, the State Emergency Management Plan for a Marine Transport Emergency (WESTPLAN MTE) was revised and it now covers formal incident controller delegations.

Further, the WA Department of Fire and Emergency Services (DFES)—the State's hazard management agency—has initiated new 'level 1' and 'level 2' marine firefighting training programs.

The operator of the ship's berth, BHP Billiton, will now provide international shore connections at its berths to improve water supply to a ship's fire line during emergencies. Additionally, BHP Billiton has aligned its standardised response checklists with those of DFES. The emergency response plan for shipboard fires is now consistent with these checklists.

Marigold's managers have taken action to address safety issues related to the maintenance and operation of the fixed fire suppression systems, as well as the ventilation closing mechanisms.

The ATSB has issued a recommendation to the ship's managers to further address the safety issue concerning the operational status of fixed fire suppression systems. It has also issued five recommendations to DFES to address issues related to shore response to shipboard fires.

Response to a large fire on board a ship in port involves the ship's crew and shore fire crews. The initial response, and fire containment, by the ship's crew requires a thorough knowledge and understanding of firefighting procedures and systems. A knowledge which needs to be effectively maintained. Where multiple shore response agencies are involved, their emergency procedures need to be consistent with each other so that individual, and team, roles and responsibilities are well understood. This will ensure that agencies can coordinate an effective response.

The ATSB's investigation report (312-MO-2014-008) is available from the ATSB website at

Man overboard fatality from Cape Splendor, Port Hedland, Western Australia on 6 October 2014
(314-MO-2014-011) website Links

On 6 October 2014, Cape Splendor's boatswain (bosun) descended to the lower platform of the bulk carrier's accommodation ladder during his lunch break. He intended to fish from this location and asked a seaman to assist. At 1250 WST, the bosun lost his balance and fell into the sea.

The seaman immediately returned to the ship's deck and threw a lifebuoy toward the bosun, before raising the alarm. The ship's crew deployed its rescue boat within 10 minutes, and an extensive air and sea search continued for 3 days. However, the bosun was not found.

The ATSB found that the bosun, and the seaman, were not wearing any flotation devices or fall prevention equipment. The bosun had seen fish below the accommodation ladder, which was in the shade. He probably saw it as a good opportunity to fish and did not consider the risks involved. Factors such as the lack of a lifejacket, wet clothing, possible entanglement with fishing gear, sea conditions and the current would have adversely affected the bosun's ability to stay afloat and swim.

The ATSB investigation also identified that the ship's safety management system procedures for working over the ship's side were not effectively implemented. Hence, the ship's crew routinely did not take all the required safety precautions when working over the side. It was also found that the crew had differing attitudes towards taking safety precautions during work and recreation times as the safety culture on board was not well developed.

Cape Splendor's managers conducted a fleet-wide review of procedures and training, to ensure ship crews complied with procedures and permits to work, with particular emphasis on working aloft and/or over the side. A number of fleet-wide memoranda describing the accident were issued to promulgate lessons learned, encourage compliance with policies and procedures and reiterate the importance of taking safety precautions during both work and leisure periods.

Figure 10: Cape Splendor's accommodation ladder

Cape Splendors accommodation ladder

Source: ATSB

The ship's managers have prohibited fishing from ships' accommodation ladders and warning signs have been posted. Man overboard recovery procedures were reviewed and the accident was highlighted in training programs.

The ATSB has issued a safety advisory notice (SAN) to shipmasters, owners and operators to promote the importance of an effective safety culture on board ships. The SAN reinforces the importance of safety awareness at all times, during both work and recreational activities.

Any task or activity that involves a person being on a ship's accommodation ladder, or other location over the side of the ship, can result in serious or fatal injury. Therefore, precautions are critical to prevent a person from falling overboard and to improve survivability in case one does fall into the water. It is important to ensure that these precautions are always taken, regardless of whether the person is engaged in work, recreational or other activities.

The ATSB's investigation report (314-MO-2014-011) is available from the ATSB website at

Rail investigations

Collision between freight trains 2MP9 and 2MP1, Mile End, South Australia on 31 March 2015 (RO-2015-007) news Links

At about 0730 (CDT) on 31 March 2015, intermodal freight train 2MP9 passed No. 1 signal at the southern end of the Mile End crossing loop. The signal was displaying a 'Calling on/Low speed' indication. The train proceeded at low speed, but subsequently collided with the rear end of intermodal freight train 2MP1, which was stationary on the main line. The collision resulted in moderate track damage and the derailment of three wagons at the rear of train 2MP1. There were no injuries to train crews.

Figure 11: Collision site near Mile End

Collision site near Mile End

Source: ATSB

The ATSB determined that the signalling and communications systems were operating correctly and as designed. The investigation found that the driver of train 2MP9, on receiving a 'Calling on/Low speed' signal indication, proceeded at a speed not greater than 25 km/h, but was unable to stop the train 'within half the distance the line ahead was clear'—as prescribed by the operational rules. The driver was aware that the operational rules stipulate that 'block ahead may be occupied or obstructed', but did not expect that train 2MP1 was stationary on the track so close ahead. As he approached train 2MP1, some stumpy vegetation and a low fence initially obscured his view of the empty flat wagons at the rear of the train. When the driver finally saw the rear of train 2MP1, he immediately made an emergency brake application, but was unable to stop the train before it collided with 2MP1.

The ATSB noted that the pathing of a train by a network control officer (NCO) onto a line occupied by a preceding train, when an alternate route is available and not obstructed, presents an elevated level of risk. Similarly, well thought out and clear communications between an NCO and the crew of an approaching train, as to the proximity of a train occupying the track ahead, can significantly enhance situational awareness and reduce operational risk.

The Australian Rail Track Corporation and SCT Logistics have implemented a range of proactive strategies for enhancing the safe operation of train movements, when entering an occupied section of track under a 'Proceed restricted authority'. This includes the use of all available infrastructure to reduce risk, encouraging communications between train drivers and NCOs where clarification of operational conditions is necessary and a review of the National Train Communications System for the Adelaide area.

The ATSB advised that train drivers should carefully consider their obligations when accepting a 'Calling on/Low speed' signal indication in relation to sighting constraints, train speed and occupation of the track ahead. In circumstances where sighting constraints may exist, drivers should consider requesting further information from the NCO before moving through the track ahead.

NCOs should carefully consider the pathing of trains under their control and the communication of information that may mitigate collision risk when dispatching trains.

The ATSB's investigation report (RO-2015-007) is available from the ATSB website at

Collision between track worker and passenger train at Guildford, Western Australia on 10 February 2015
(RO-2015-002) news Links

On 10 February 2015, a Public Transport Authority (PTA) maintenance crew commenced work at Meadow Street, Guildford, Western Australia. The crew's assigned tasks included maintaining the pedestrian gates adjacent to the level crossing.

At about 1035 WST one of the track workers was struck by a Perth-bound suburban passenger train. The track worker sustained fatal injuries.

Figure 12: Meadow Street level crossing and pedestrian gate

Meadow Street level

Source: ATSB

The ATSB investigation found that the PTA maintenance workers had not implemented any form of track worker protection at the work site. This was partially due to the PTA not having documented instructions specifying the level of protection required, preferring that track workers make their own assessment based on their knowledge of the Network Rules. The ATSB found that, under these arrangements, track workers could make an incorrect assessment, placing themselves at a greater risk of being struck by a train.

A review of the safeworking training provided to the track workers found that the training material did provide a suitable level of safeworking knowledge.

Following the occurrence, the toxicology report on the deceased track worker identified the presence of amphetamine and methamphetamine—methamphetamine being a prescribed drug under the Rail Safety Regulations 2011. The use of stimulants such as methamphetamine is associated with a range of neurocognitive effects in humans that may affect performance.

The ATSB found that in this instance, the presence of a prescribed drug within the worker's system appeared to be a relatively isolated case. An examination of the company's drug and alcohol policy and procedures found them to be generally effective in managing drugs and alcohol in the workplace.

The PTA issued a safety alert following the incident, to highlight the importance of implementing the correct level of track worker protection. The subsequent introduction of new safeworking rules, track access accreditation levels and training further supported this.

Further, the PTA has created the role of Workplace Trainer and Assessor with the task of ensuring track workers comply with the network rules, by way of competency-based assessments. Implementation of a new track access accreditation system, with improved training and job mentoring, has also commenced.

The ATSB advised that this incident strongly emphasises the need for rail transport operators to provide clear and concise work instructions to employees working within the railway corridor. It also highlights the potential for recreational and other drug use to impair performance and affect workplace safety.

The ATSB's investigation report (RO-2015-002) is available from the ATSB website at

Fatality at Heyington Railway Station, Toorak, Victoria on 22 February 2014 (RO-2014-005) news Links

At about 2355 AEDT on 22 February 2014, an 18-year-old male was fatally injured at Heyington Railway Station in Toorak, Victoria, when he fell between a moving train and the platform. He was running alongside the moving train when he fell in an attempt to board it while passengers inside the train were forcibly holding the carriage doors open.

The train was equipped with a traction interlocking device to prevent the train from moving while its carriage doors were open. The device, as designed, deactivated after a period of time and allowed the train to depart with the doors held open.

Due to the curvature of the track, a wide gap existed between the mid-body of the carriage and the platform.

Figure 13: Heyington Railway Station


Source: Chief Investigator, Transport Safety (Vic)

Metro Trains Melbourne (MTM) has commenced a risk review of the door open traction interlock timing on their rolling stock.

In order to minimise the gap between the train and platform, MTM has realigned the track at Heyington railway station and a rubber finger coping has been installed along the entire edge of the platform face. Further, a barrier has been constructed at the platform entrance to deter passengers from running for the train.

MTM has also completed a survey of all the stations to identify curved track and platforms of higher risk. In the short term these platforms have had 'Mind the Gap' signs painted on them. Announcements are also made to warn passengers of the gap. Works plans have been developed to institute further risk measures in the long term.

The ATSB advised that rail operators should ensure that safety systems fitted to passenger trains are designed and operated to ensure the safety of patrons in the event of interference with the normal operation of train doors.

The ATSB's investigation report (RO-2014-005) is available from the ATSB website at

Derailment of Sydney Trains passenger train 602M near Edgecliff station, Sydney, New South Wales
on 15 January 2014 (RO-2014-001) news Links

At about 1654 AEDT on 15 January 2014, a Sydney Trains service made up of two four-carriage Tangara electric multiple units, entered the underground section of the Eastern Suburbs Line, under Sydney city centre, heading towards its destination, Bondi Junction. Some smoke and a burning smell were apparent, emanating from the train at Central Station and at all subsequent stations to Bondi Junction. A number of station and train crewing staff were aware of this, but the condition was not reported to the appropriate network control officer, as required under Sydney Trains' Network Rules and Procedures.

The train terminated at Bondi Junction, where a different driver took control before it departed on its return journey. It then travelled to the next station, Edgecliff. Shortly after departure from Edgecliff, at 1726, the lead bogie of the third carriage derailed due to a broken axle. A piece of angle iron, which became dislodged from the track infrastructure, penetrated the floor of the third carriage and entered a space occupied by passengers.

Figure 14: Derailed bogie on train 602M

Derailed bogie on train 602M

Source: Office of Transport Safety Investigations (NSW)

The ATSB found that an unauthorised, non-standard, repair had been carried out on the axle in December 1998, or January 1999, which introduced stress initiators. This caused a crack to develop which, over time, propagated to the extent that the axle failed in service.

It was also determined that a number of organisational factors contributed to the incident. Examples of poor communication, and lack of adherence to procedures and reporting lines, led to the train's continued service and subsequent derailing.

Sydney Trains, along with their maintenance contractors, undertook an archival document search and determined that seven axles, including the failed axle, had been repaired in the same way. All were immediately removed from service.

Sydney Trains, after conducting its own investigation into the circumstances surrounding the incident, produced a number of safety recommendations which they are considering through their own Safety Action Management procedures.

The ATSB advised that rail operators should ensure maintenance procedures are followed and that non-standard repairs comply strictly with an approved variation and do not introduce new risks to operations.

Also, rail operators should review their internal training, and communication pathways, both within and between business units/operational areas, to ensure that critical communication can occur in line with best current Rail Resource Management principles.

The ATSB's investigation report (RO-2014-001) is available from the ATSB website at