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Aviation investigations


The investigations below cover a variety of operational types, including parachuting, aerial photography, charter and regular public transport.

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Loss of control involving Cessna Aircraft Company U206G, VH-FRT Caboolture Airfield, Queensland, 22 March 2014 (AO-2014-053)

The accident occurred when the aircraft was conducting tandem parachuting operations from Caboolture aerodrome in Queensland. On board were the pilot, two parachuting instructors and two tandem parachutists. Shortly after take-off, the aircraft climbed to about 200 feet before aerodynamically stalling and colliding with the ground (Figure 1). Tragically, all five occupants died in the accident.

Figure 6: Accident site wreckage distribution

 Accident site wreckage distribution

Source: ATSB

Extensive fire damage prevented examination and testing of most of the aircraft components. Due to that fact, a mechanical defect could not be ruled out as a contributor to the accident. Despite this, the investigation identified a number of safety issues associated with occupant restraint, modification of parachuting aircraft, and scope for improving the risk controls associated with parachuting operations.

In response to the ATSB’s investigation, the Australian Parachute Federation (APF) and Australia’s aviation safety regulator, CASA, undertook action to improve the safety of parachuting operations.

The APF mandated that all member clubs/operations have their own safety management system to proactively assess and mitigate risks. The APF has also enhanced their audit process and increased the number of full-time safety personnel to audit their member organisations.

CASA has increased the available information on their website about the risks associated with sports aviation. They also introduced an Airworthiness Bulletin to provide guidance about co-pilot side flight control modifications.

The ATSB welcomed the APF’s and CASA’s safety action, but considered that more could be done to improve safety for skydiving operations.

In response to an identified safety issue, the ATSB recommended that CASA take safety action to increase the fitment of the Cessna secondary pilot seat stop modification. That safety issue affects all Cessna aircraft and not just those being used for parachuting operations.

In addition, the ATSB recommended that CASA introduce measures to reduce the risk associated with the aircraft serviceability, pilot competence and adequate regulatory oversight for parachuting operations.

Furthermore, the ATSB recommended CASA and the APF increase the use of dual-point restraints in parachuting aircraft due to the enhanced survivability that dual point restraints provide.

The ATSB’s investigation report (AO-2014-053) is available from the ATSB’s website at www.atsb.gov.au

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Collision with terrain involving B200 King Air VH-ZCR at Essendon Airport, Victoria, 21 February 2017 (AO-2017-024)

The pilot was conducting a flight from Essendon Airport, Victoria, to King Island, Tasmania. On board were the pilot and four passengers.

Witnesses reported that the take-off roll along the runway was longer than normal and after becoming airborne, the aircraft was observed to yaw left. Shortly after take-off, the pilot broadcast a MAYDAY call. The pilot repeated the word ‘MAYDAY’ seven times within that transmission. No additional information regarding the nature of the emergency was broadcast.

The aircraft reached a maximum height of approximately 160 ft above ground level while tracking in an arc to the left of the runway centreline (Figure 7). The aircraft subsequently collided with a building in the Essendon Airport retail precinct. The pilot and passengers were fatally injured and the aircraft destroyed. Additionally, a number of people on the ground received minor injuries.

Figure 7: Aircraft track from Airservices Australia ADS-B data

Aircraft track from Airservices Australia ADS-B data

Source: Google Earth, modified by the ATSB Note: All heights above ground level.

Figure 8: Accident site overview

Accident site overview

Source: Metropolitan Fire Brigade (Melbourne), modified by the ATSB

On-site examination of the wreckage did not identify any pre-existing faults with the aircraft that could have contributed to the accident. Examination of the engines found that the cores of both were rotating and that there was no evidence of pre-impact failure of either engine’s internal components. However, a number of engine components were retained for further examination and testing. The ATSB also retained the propellers, several airframe components, documents and electronic devices for further examination.

The aircraft’s fire-damaged cockpit voice recorder (CVR) was recovered from the accident site and while the CVR was successfully downloaded, no audio from the accident flight was recorded. The ATSB is examining the reasons for the failure of the CVR to operate on the accident flight.

The investigation is continuing.

The ATSB’s preliminary investigation report (AO-2017-024) is available from the ATSB website at www.atsb.gov.au

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In-flight pitch disconnect involving ATR 72, registered VH-FVR, 47 km WSW of Sydney Airport, New South Wales, 20 February 2014 (AO-2014-032)

The Virgin Australia Regional Airlines ATR 72 aircraft was operating on a scheduled passenger flight from Canberra, Australian Capital Territory, to Sydney, New South Wales. While on descent into Sydney, the crew were attempting to prevent an increase in the airspeed from exceeding the maximum permitted airspeed. They inadvertently made uncoordinated dual control inputs that resulted in a pitch disconnect. The aircraft’s horizontal stabiliser was significantly damaged during the occurrence.

Figure 9: CCTV image showing VH-FVR (circled) taxiing inbound at Sydney Airport on 20 February 2014 following the in-flight pitch disconnect. Note the angle of the horizontal stabiliser relative to the wings.

CCTV image showing VH-FVR (circled) taxiing inbound at Sydney Airport

Source: Sydney Airport, modified by the ATSB

Figure 10: Underside of the horizontal stabiliser, with aerodynamic fairings removed. Note: the thick yellow line indicates cracking.

Underside of the horizontal stabiliser, with aerodynamic fairings removed

Source: ATSB

During the investigation, it came to the ATSB’s attention that there had been a number of pitch disconnects involving ATR 42 and 72 aircraft around the world. There were various factors leading to those pitch disconnects; however, several were identified to have been a result of dual control inputs.

With the VH-FVR occurrence indicating that a pitch disconnect at high speed could potentially result in catastrophic damage to the aircraft, the ATSB determined that the number of inadvertent pitch disconnects constituted a significant risk to the continued safe operation of the ATR 42/72 fleet. As such, on 15 June 2016, the ATSB released an interim report which included the safety issue:

Inadvertent application of opposing pitch control inputs by flight crew can activate the pitch uncoupling mechanism which, in certain high-energy situations, can result in catastrophic damage to the aircraft structure before crews are able to react.

As the investigation progressed, the ATSB identified that, as a result of flexibility in the system and unavoidable control column movement, transient elevator deflections occur during a pitch disconnect event which lead to aerodynamic loads. At high speeds, those loads could exceed the strength of the aircraft structure. It was also identified that the aircraft manufacturer had not accounted for those transient deflections during the design and certification of the aircraft type.

Given the potential significance of this finding, the ATSB commissioned a peer review of the evidence and analysis by the United Kingdom’s Air Accidents Investigation Branch (AAIB). The peer review validated the ATSB’s findings and on 5 May 2017, after notifying the manufacturer, the European Aviation Safety Agency (EASA), CASA, and the Australian operator, the ATSB released a second interim report. The second interim report contained the following safety issue:

The aircraft manufacturer did not account for the transient elevator deflections that occur as a result of the system flexibility and control column input during a pitch disconnect event at all speeds within the flight envelope. As such, there is no assurance that the aircraft has sufficient strength to withstand the loads resulting from a pitch disconnect.

The aircraft manufacturer made an undertaking to conduct a detailed engineering analysis of the transient elevator loads during a pitch disconnect. The ATSB acknowledged the efforts of the aircraft manufacturer to resolve this safety issue, but retained a level of ongoing concern as to whether the aircraft has sufficient strength to withstand the loads resulting from a pitch disconnect. Consequently, as part of the second interim report, the ATSB issued recommendations to ATR, EASA and CASA to ensure that the engineering analysis is conducted as soon as possible, and if the analysis identifies that the aircraft does not have sufficient strength, immediate action be taken to ensure the ongoing safe operation of ATR 42 and 72 aircraft.

This complex investigation is ongoing and includes aspects relating to the operational and human factors of what precipitated the uncoordinated dual control inputs. Examination of the organisational factors that led to the aircraft conducting a further 13 flight sectors, before the damage from the pitch disconnect was identified, are also being examined in detail.

The ATSB’s two interim reports (AO-2014-032) are available from the ATSB website at www.atsb.gov.au

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Traffic management occurrence involving Airbus A320, VH-VQS and Beech Aircraft Corporation BE 76, VH-EWL at Ballina/Byron Gateway Airport, New South Wales, 14 January 2016 (AO-2016-003)

While taking-off from Ballina/Byron Gateway Airport, an Airbus A320, registered VH-VQS (VQS) and operated by Jetstar Airways, came in close proximity to Beech Aircraft Corporation BE-76 Duchess, registered VH-EWL (EWL). The Duchess was conducting navigation training in the vicinity of the runway and was noticed by the flight crew of VQS during the take-off roll and below the maximum speed from which they could stop. The take-off was continued and while manoeuvring to maintain separation from EWL, the crew of VQS received master warning/caution alerts regarding the aircraft’s configuration. The crew also commenced flap retraction at low altitude and turned contrary to operator-prescribed departure procedures before departing for Melbourne. There were no injuries or damage to equipment recorded during the occurrence.

Figure 11: Jetstar A320, Beech Aircraft Corporation BE-76 Duchess and Ballina/Byron Gateway Airport

Jetstar A320, Beech Aircraft Corporation BE-76 Duchess and Ballina/Byron Gateway Airport

Source: Google Maps and supplied images

The ATSB found that despite an increase in passenger numbers and a mixture of traffic, Ballina/Byron Gateway Airport operated without the support of air traffic information and/or services. While recognising that a direct comparison between airports is difficult, Ballina also experienced a higher number of incidents relating to communication and separation issues compared to airports with similar traffic levels. The ATSB also found that a number of non-standard operating practices and procedures led to a breakdown of crew resource management and the ability to adequately manage the dynamic situation by the crew of VQS. Finally, the ATSB found that the level of communication between the crews of VQS and EWL was inadequate to develop a shared mental model of what each crew was intending to do to ensure separation.

Following a recommendation by CASA, the operator of Ballina/Byron Gateway Airport implemented a certified air/ground radio service (CA/GRS) to provide weather services and traffic information at the airport. This service commenced in March 2017 and operates daily between 0800 and 1800 local time. The CASA Office of Airspace Regulation planned a post-CA/GRS implementation review in mid-2017 to assess its effectiveness.

Additionally, Jetstar Airways proposed to increase their annual audit schedule of common traffic advisory frequency operations, reviewed their jump seat policy when operating in such aerodromes to assist in distraction management, and altered their training matrix to further include exercises pertaining to levels of assertion and upwards managing by first officers.

Operations at non-controlled airports remain a SafetyWatch priority for the ATSB. This occurrence highlights that traffic separation in that environment relies on a clear and shared plan between involved aircraft.

Adherence to standard operating practices and procedures promotes a shared understanding of crew’s actions by making them ordered and predictable to the other pilots. As well as reducing the likelihood of task omission or duplication during times of high workload, standardised practices and procedures decrease the mental demand on flight crew when carrying out a set of complex steps, allowing for better processing of unexpected events.

The ATSB’s investigation report (AO-2016-003) is available from the ATSB website at www.atsb.gov.au

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Rail investigations


The two rail investigations described below identify safety concerns associated with level crossings and weather events.

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Level crossing collision between freight train 8834N and road-train truck, Tullamore Rd, Narromine, New South Wales, 23 September 2015 (RO-2015-016)

On 23 September 2015, an eastbound road-train truck, hauling grain, collided into the side of Pacific National grain train 8834N (travelling on the main line between Narromine and Peak Hill) at the Tullamore–Narromine Road railway crossing, about four kilometres south-west of Narromine, in New South Wales. The railway crossing was controlled by flashing lights, an audible warning device (bell), passive warning signs installed on the road approaches and road surface markings.

Figure 12: Post collision fire, road-train truck (trailers) at Tullamore–Narromine Road railway crossing

Post collision fire, road-train truck (trailers) at Tullamore–Narromine Road railway crossing

Source: P Smith

The collision and a post-impact fire destroyed the prime mover and one of the two trailers; the truck driver was fatally injured. The crew of the train were physically unhurt. As a result of the impact, two wagons were damaged; one of which derailed. Some of the railway crossing infrastructure (flashing lights) was destroyed and required replacement.

The ATSB found that the driver of the road-train truck was probably travelling too fast for the prevailing conditions, and entered the Tullamore–Narromine Road railway crossing while it was active, and the flashing lights were operating. It was concluded that the truck driver’s attention was probably focused on negotiating the sweeping right-hand curve that preceded the crossing, at a critical time when he needed to check for the activation of the crossing. It is likely that when the driver perceived that the flashing lights were operating, he was too close to the crossing to stop, and collided with the train.

The ATSB identified a number of areas of potential improvement related to road design (signage and standards associated with railway crossing traffic control) especially with respect to curved approaches, before railway crossings.

The truck owners, the Narromine Shire Council, and Standards Australia have implemented a range of initiatives to reduce the risk of a similar occurrence in the future, including:

  • enhanced employee training and medical assessment initiatives
  • provision of additional (road) approach passive warning signs, (W7-4) plus a review of road alignment and railway crossing road approach speeds
  • a review of AS 1742.7-2016, with respect to railway crossing approaches, in particular curved approaches, and the location of signage.

The ATSB advised that although the road rules (NSW–Road Rules 2014) make motorists primarily responsible for avoiding a collision with a train at railway crossings, prudent road design and/or advance warning of a train’s presence at railway crossings should be considered as a strategy to lower the risk of road and rail vehicle collisions.

The ATSB further noted that road and rail authorities should consider added measures to enhance the situational awareness of motorists approaching railway crossings, especially at locations with restricted sighting due to curved approach roads.

It is imperative that road vehicle drivers always approach railway crossings with extreme care. The level of care and attention required increases as road vehicle gross mass increases.

The ATSB’s investigation report (RO-2015-016) is available from the ATSB website at www.atsb.gov.au

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Derailment of freight train near Julia Creek, Queensland, 27 December 2015 (RO-2015-028)

On 26 and 27 December 2015, the rail traffic crew of trains 9E56 and 9T92 encountered wet weather as they travelled toward Julia Creek. The Bureau of Meteorology (BoM) had issued a series of localised severe thunderstorm warnings for the North West forecast district, which was normal during the wet season. The Network Control Officer (NCO) at the Queensland train control centre in Townsville was monitoring information on the BoM website and had received some information from the rail traffic crews who were travelling along the section. The NCO acted on the information available by arranging track inspections of the relevant sections of track west of Julia Creek.

As these inspections were occurring, train 9T92 continued to travel toward Julia Creek from the east. Shortly after passing through a section of track where floodwaters had previously overtopped the track and receded, the crew of train 9T92 encountered another area where floodwater had overtopped the track. At this location, however, the floodwater had scoured the ballast and compromised the integrity of the track.

The driver became aware of the washout only moments before the locomotive impacted and derailed, causing the locomotive to tip on its side. After sighting the washout, the train crew could do nothing to prevent, or lessen, the impact of the incident.

Figure 13: Derailed train 9T92

Derailed train 9T92

Source: Queensland Police Service

The ATSB found that scouring of the ballast and formation adjacent to the 617.190 km point by floodwater meant that the track could not support the weight of train 9T92 as it passed over the affected area. The resulting deformation in alignment of the track initiated the derailment. Reporting procedures implemented by Queensland Rail (the track manager) and Aurizon (the train operator) provided insufficient guidance to the NCO or rail traffic crew to identify and respond to potential hazards from a wet weather event.

Queensland Rail has issued Safety Alerts to improve the effectiveness of the current network rules in relation to managing hazards associated with weather events. A review of weather monitoring services and the upskilling knowledge of relevant personnel on interpreting meteorological information has also commenced. Queensland Rail has commenced a review into the feasibility of adopting the Australian Standard AS7637 Railway Infrastructure – Hydrology and Hydraulics.

Aurizon has introduced respiratory protection masks for train crew on trains transporting acid. Additionally Aurizon continues to reassess the emergency evacuation procedures, locomotive windscreens and secondary communication opportunities/options.

The ATSB advised that rail infrastructure managers must implement adequate operational procedures and training programs to ensure the timely identification and management of a hazard to the integrity of their rail infrastructure, such as a weather event. Rolling stock operators must ensure that their training programs include relevant operational procedures enabling consistent assessment, reporting and response by train crew to conditions that may adversely affect the integrity of rail infrastructure or trains.

The ATSB’s investigation report (RO-2015-028) is available from the ATSB website at www.atsb.gov.au

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Marine investigations


Of the two marine safety investigations described below, the first relates to marine work practices loading cargo. The other relates to mooring in high wind conditions.

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Fatality on board Skandi Pacific, off the Pilbara coast, Western Australia, 14 July 2015 (322-MO-2015-005)

In the early hours of 14 July 2015, the offshore support vessel (OSV) Skandi Pacific was loading cargo containers from the semi-submersible oil rig Atwood Osprey at its offshore location, about 90 miles north-west off Dampier. Shortly after 0505 WST, cargo transfer was stopped due to worsening weather conditions. Skandi Pacific was moved 30 m away from the rig with the rough seas still on its port quarter. Two crewmembers then began securing cargo on the vessel’s aft deck.

The crewmembers slackened the securing chain they had used to secure the containers on the starboard side to better secure the entire stow. At about 0523 WST, two large waves came over Skandi Pacific’s open stern, shifting the unsecured containers forward. One of the crewmembers was trapped between the moving containers, chains and a skip and suffered fatal crush injuries.

Figure 14: Skandi Pacific

Skandi Pacific

Source: Mr Liam Hock Wu

The ATSB investigation found that the risks associated with securing the cargo in the prevailing weather conditions had not been adequately assessed. The fatally injured man was standing in a dangerous location near the unsecured cargo containers when they shifted.

The investigation identified that Skandi Pacific’s safety management system (SMS) procedures for working/securing cargo on deck in poor weather were inadequate, with no clearly defined weather limits. Further, there were no clearly defined limits for excessive water on deck that necessitated stopping operations. Individuals were left to make difficult, and necessarily subjective, decisions about whether or not to stop work.

The ATSB also found that Skandi Pacific’s managers had not adequately assessed the inherent high risks associated with seas coming over the vessel’s open stern when work, including cargo handling operations, was being undertaken on its aft deck.

Proactive safety action by Skandi Pacific’s managers to avoid a similar accident included improved cargo handling practices across its OSV fleet. Amongst these measures are updated procedures for working in adverse weather and cargo loading, including specific weather condition limits. In addition, existing risk assessments for offloading deck cargo at installations were updated to include a section on risks associated with securing cargo.

The safety action taken by the vessel’s managers adequately addressed the safety issues related to cargo handling/securing in adverse weather. The action taken partially addressed the safety issue with regard to open stern vessels. Therefore, the ATSB issued a safety recommendation to the vessel’s managers to undertake further work to better address the risks associated with the use of vessels with open sterns. The ATSB also issued a safety advisory notice to shipmasters, owners, and operators of OSVs to highlight the risks posed by the open stern vessels to the industry more broadly.

Offshore support vessel operations are inherently high risk because they often occur in exposed locations in a particularly dynamic environment. Multiple factors, including weather conditions, schedule requirements, time of day, limited crew numbers, restrictions due to vessel design and systems, amongst others, add complexity to operations. Therefore, risk assessments are critical, with the weather and its impact on factors, such as an open stern, are invariably a vital consideration.

The ATSB’s investigation report (322-MO-2015-005) is available from the ATSB website at www.atsb.gov.au

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Breakaway of Spirit of Tasmania II at Station Pier, Port Melbourne, Victoria, 13 January 2016 (324-MO-2016-001)

On the afternoon of 13 January 2016, the roll-on/roll-off passenger ship Spirit of Tasmania II was loading cargo, vehicles and passengers at Station Pier, Melbourne. At 1752 EDST, strong wind gusts blew the ship off the wharf and all but two of the ship’s mooring lines (on the bow) parted. After breaking away, the stern swung around until the ship was 90 degrees to the wharf, parallel to nearby Port Melbourne Beach and in danger of grounding. While waiting for tugs to assist, the ship’s propulsion and thrusters were used to maintain its position and prevent grounding. By 1905 EDST, the ship was back alongside the wharf, assisted by two tugs.

Figure 15: Spirit of Tasmania II after the breakaway

Spirit of Tasmania II after the breakaway

Source: George Donikan

The ship suffered minor damage to its lower bow ramp and bow doors. Shore infrastructure suffered extensive damage to the elevated roadway and ramp arrangement on the wharf and minor damage to wharf structures. No one was injured.

During the afternoon of 13 January, a band of severe thunderstorms passed across the location of Spirit of Tasmania II, with little warning. As the ship’s bridge was unattended throughout the port stay, none of its crew saw indicators of the approaching storm until just before the breakaway. The ship’s crew responded swiftly. The bridge was manned and machinery was operational by the time the ship had turned 90 degrees to the wharf. The ship’s movement was then controlled using its thrusters and main propulsion until, with tug assistance, it was returned to the wharf.

The ship’s managers, TT-Line Company, implemented immediate changes to shipboard weather monitoring and notification arrangements, along with changes to heavy weather and mooring procedures. These changes included: weather triggers for increased shipboard readiness; immediate notification of weather warnings; access to the Bureau of Meteorology (BoM) website from the bridge; changes to the wind speed alarm settings; and requiring all mooring lines to be held on the winch brakes.

TT-Line also engaged external marine consultants to complete extensive investigations and analysis into the mooring requirements and design for Station Pier. The consultants completed mathematical modelling and incident replication simulations, and further analysis is intended to define operational parameters and recommend any alterations to berthing arrangements and infrastructure. The ATSB issued one recommendation to TT-Line to complete safety action to adequately address the safety issue with respect to moorings.

The Victorian Ports Corporation’s (Melbourne) action included Melbourne vessel traffic service broadcasting BoM weather warnings on VHF channel 12. All masters of ships in port waters, including at berth or anchorage, are to ensure a listening watch is maintained at all times.

The BoM verified its subscription service with the Victorian Ports Corporation (Melbourne) and continues to upgrade its marine weather services. This includes a one-stop webpage on its website for improved education, information and accessibility to marine and ocean services.

All ships, especially those with high windage, are prone to breaking away from moorings during short-term events such as thunderstorms and squalls. The risks this presents to ships with large numbers of people on board mean that weather monitoring, mooring systems and procedures need to be regularly checked and verified for changing weather conditions.

The ATSB’s investigation report (324-MO-2016-001) is available from the ATSB website at www.atsb.gov.au