Collision between a Hong Kong registered bulk carrier, Silver Yang and an Australian yacht, Pink Lady

The Australian Transport Safety Bureau (ATSB) is investigating the collision between the bulk carrier Silver Yang and the yacht, Pink Lady.

Mr Mike Squires, Acting Director of Surface Safety Investigations, confirmed the known details of the incident and outlined the investigation process at a media briefing held at Parliament House today, Wednesday, 9 September at 2.30pm.

Two ATSB investigators departed for Queensland this morning to commence the investigation. Brisbane Water Police are also assisting.

The Pink Lady was expected to berth at Southport sometime this afternoon. The yacht was dismasted in the collision.

According to Mr Squires, the ATSB was advised of the incident by AUSSAR at about 3.00am this morning. The collision between the yacht, Pink Lady and a bulk carrier Silver Yang is reported to have occurred about 15 miles east of Point Lookout, North Stradbroke Island, Queensland.

The ship Silver Yang is bound for China to discharge its cargo. The flag state, Hong Kong, are assisting with the ship side of the investigation.

There is no report of injuries.

There was reported radio contact between the ship and yacht after the incident but details of the communication are not known.

It is not known how long an investigation such as this will take. The ATSB will release a Preliminary Factual report within about 30 days. Should any critical safety issues emerge that require urgent attention, the ATSB will immediately bring such issues to the attention of the relevant authorities who are best placed to take prompt action to address those issues.

Collision between a Hong Kong registered bulk carrier, Silver Yang and an Australian yacht, Ella’s Pink Lady

On 20 October 2009, the Australian Transport Safety Bureau (ATSB) will be holding a media conference to accompany the release of its Transport Safety Investigation Preliminary Report, MO-2009-008, into the collision between Silver Yang and Ella's Pink Lady. The incident occurred off Point Lookout, Queensland, on 9 September 2009.

Mr Peter Foley, Director, Surface Safety Investigations will discuss the preliminary report, which is a statement of facts known at this time, and will be talking about the investigation activities conducted up to this point.

The media conference is being held at the ATSB Canberra Office, on Tuesday, 20 October 2009.

Where: 62 Northbourne Avenue, Canberra City ACT

Time: 10:30 am (local time)

All future media enquiries must be directed to the media contact listed below.

Media Conference Alert: Collision between a Hong Kong registered bulk carrier, Silver Yang and an Australian yacht, Pink Lady

The Australian Transport Safety Bureau (ATSB) is investigating and two investigators departed for Queensland this morning to commence the investigation. The yacht is expected to berth at Southport later this afternoon.

Mr Mike Squires, Acting Director of Surface Safety Investigations will discuss factual information known to the ATSB at this time and will outline the investigation process at a media conference today, Wednesday, 9 September 2009.

Where: 62 Northbourne Avenue, Canberra City ACT (ATSB Central Office)

Time: 2.30 pm (local time)

No further media briefings will be conducted by the investigation team. After this briefing, all media enquiries must be directed to the media contact listed below.

Collision with terrain – near Kokoda, PNG – 11 August 2009 – P2-MCB, De Havilland DH-6 Twin Otter

The Papua New Guinea Accident Investigation Commission (AIC) has released its Preliminary Factual Report into the collision with terrain that occurred near Kokoda, Papua New Guinea on 11 August 2009, involving a De Havilland DH-6 Twin Otter aircraft, registration P2-MCB. The AIC is investigating this accident, together with support from the Papua New Guinea Department of Transport, in accordance with its obligations under Annex 13 to the Convention on International Civil Aviation. The AIC requested the Australian Transport Safety Bureau (ATSB) to assist their investigation by providing investigator support, information and technical advice and facilities support.

In accordance with paragraph 5.23 of Annex 13, the ATSB appointed an Accredited Representative and a number of advisors to the Accredited Representative (ATSB investigators) to assist the AIC during the on-site phase, in the technical examination of a number of recovered aircraft items and components, and as requested by the AIC during the remainder of the investigation.

The ATSB is reproducing the AIC report titled Aircraft accident investigation interim report, Collision with terrain, P2-MCB, De Havilland DHC 6-300, 6 NM SSE Kokoda, 11 August 2009 on its web site with the permission, and on behalf of the Accident Investigation Commission.

Any media enquiries in respect of the AIC report and ongoing investigation should be directed to:

Mr William Vate
Telephone: +675 325 7500, ext 506
Facsimile: +675 323 3339

All other enquiries in regard to the ongoing investigation should be directed to:

Papua New Guinea Department of Transport
Accident Investigation Commission
C/- Po Box 1489,
Port Moresby
National Capital District
Papua New Guinea

Telephone: +675 325 7500, ext 508
Facsimile: +675 323 6198
E-mail: airtransport@datec.net.pg

Derailment of Train 5MB7 at Benalla

The ATSB has found that the major derailment of an Interail freight train at Benalla in Victoria on 2 June 2006 occurred because the train driver did not correctly interpret and respond to a signal.

The Australian Transport Safety Bureau investigated the accident which resulted in of the derailment of two locomotives which sustained heavy damage along with 19 wagons and two track machines which were located in an adjacent siding. A nearby Victorian Railway Institute Hall also sustained heavy structural damage as a result of the derailment.

There were no serious injuries to the train crew or other people.

The investigation concluded that the driver of the train failed to correctly interpret and then respond to a signal and that the co-driver was ineffective in preventing the derailment as he was pre-occupied and not fully alert.

In the interest of enhancing future rail safety the ATSB has made a series of recommendations which include a review of crew coordination, an examination of mentoring responsibilities, and a review of processes for the re-certification of drivers.

Cannabis and mobile telephone probably contributed to fatal level crossing collision

The ATSB has found that the driver of a motor vehicle fatally injured in a collision with a train on 5 June 2006, was under the influence of cannabis and probably distracted by his mobile telephone at about the time of the accident.

The Australian Transport Safety Bureau has released its report into the accident which occurred at a level crossing on Thurgoona Road on the northern outskirts of Albury at approximately 1:22 pm on 5 June 2006. The 1986 Holden Commodore drove at a steady speed of less than 60 km/h into the path of a Sydney bound CountryLink XPT passenger train which was travelling at between 120 and 130 km/h at the point of collision.

The Commodore was destroyed by the collision and the 19 year old male driver was thrown from the car and fatally injured. There were no physical injuries to witnesses, crew or passengers of the train.

The investigation found that the level crossings flashing lights and warning bells were operating at the time of the collision and that the train driver had sounded the trains horn when he realised the car was not going to stop at the lights.

Toxicology results from the fatally injured driver were positive for cannabis. The concentration of the drug in the drivers blood exceeded levels where studies have indicated performance impairment becomes truly prominent across all drivingrelated performance measures.

The investigation also found that the motor vehicle drivers mobile telephone probably rang at or around the time that the car was approaching Thurgoona Road level crossing. While the driver did not answer the call, the ringing telephone probably distracted him from the driving task.

The ATSB concluded it was likely that combined, these two factors contributed to the motor vehicle driver not responding appropriately to the level crossing flashing lights and bell, and subsequently driving into the path of the train.

The ATSB has recommended raising public awareness of the risks associated with cannabis use and mobile telephones with respect to driving performance. The investigation also noted that at the completion of the Albury Wodonga Hume Freeway Project (scheduled for mid 2007), the road bridge would result in the closure of the level crossing, achieve grade separation and eliminate the risk of future level crossing accidents at Thurgoona Road.

Track misalignment causes derailment

An ATSB investigation has found that a number of factors combined to cause the derailment of a freight train at Yerong Creek in southern NSW on 4 January 2006, any one of which may not have resulted in a derailment in its own right.

The Australian Transport Safety Bureau investigation into the derailment concluded that a track misalignment occurred as a result of localised stresses in the rail that had built up until the track moved as the train passed over it.

The track at this location, the main rail corridor between Melbourne and Sydney, has rails that have been welded into one continuous length, in accordance with modern international practice.

The investigation found that the track had not reacted evenly to the forces upon it, and that this had led to a fault in the track, in the form of excessive localised stress in the area of the misalignment.

The investigation found that such localised stresses are very rare, and difficult to detect, even with the best modern technology.

The ATSB acknowledges that both the ARTC and the NSW rail regulator have procedures in place to reduce as much as possible the risk of track stresses building up to the point of track instability.

The ATSB has issued a safety advisory notice to all track maintainers in Australia to highlight this limitation of present technology when managing continuous welded rail.

Copies of the report can be downloaded from the ATSB's internet site.

Final ATSB report into the operational non-compliance at Perth Airport on 9 May 2008

The Australian Transport Safety Bureau (ATSB) has released its final investigation report into the serious incident at Perth Airport, WA on 9 May 2008, involving an approach and landing by a Boeing Company 737-800, registered PK-GEF, during a period of planned runway works.

The ATSB report found that the permanent runway 21 threshold and touchdown markings were not required to be obscured and were clearly visible to the flight crew. Those markings continued to provide approach and landing cues to the normal touchdown zone, which was located within the runway works area. The use of 6 m closed runway markings, in lieu of 36 m markings as recommended by the International Civil Aviation Organization (ICAO), increased the risk of a flight crew conducting a visual approach to the still-visible permanent threshold/touchdown area.

The report outlines a number of differences between the closed runway markings as recommended by ICAO Annex 14 Aerodromes, and the Civil Aviation Safety Authority (CASA) Manual of Standards (MOS) Part 139 Aerodromes.

A number of safety issues were identified as a result of the ATSB investigation. Safety action undertaken by the aircraft operator, the airport operator, and CASA in response to those safety issues should, when completed, reduce the risk of a similar event in the future.

Copies of the report can be downloaded from the ATSB's internet site at www.atsb.gov.au or obtained from the ATSB by telephoning 1800 020 616.

The Ghan level crossing collision: final ATSB report

The ATSB investigation of a collision between The Ghan passenger train and a double road-train has found that the accident occurred because the road-train was driven through a 'Stop' sign at a level crossing at an estimated speed of 50 km/h, linked to local truck driver practice and medical issues.

The final report by the Australian Transport Safety Bureau also found that The Ghan hit the road-train just behind its prime mover at a speed of 101 km/h on the afternoon of 12 December 2006 at the Fountain Head Road level crossing at Ban Ban Springs, about 170 kilometres south-east of Darwin.

Both of the train's locomotives, a wagon and nine passenger carriages subsequently derailed. Many of the 64 passengers and 17 staff on board sustained minor injuries with the driver of the road-train and one passenger hospitalised for several days following the collision.

The road-train driver had been carrying road-base material across the Fountain Head Road level crossing about thirty times each day for the previous month and had apparently only seen about four trains in that time. It was the driver's practice, and that of other drivers engaged in the same work, to slow rather than stop at the level crossing.

The train driver had appropriately sounded the locomotive horn three times before the collision and the headlight was illuminated and on high beam.

The investigation found that road-train driver had severe bilateral hearing loss, to the extent that he would not have been eligible to hold his unrestricted heavy vehicle licence, and that this hearing loss would have compromised his ability to hear the locomotive horn in the time leading to the collision.

The ATSB also noted concerns regarding the adequacy of sighting distances at level crossings for vehicles up to 53.5 metres long using such crossings.

The ATSB investigation report acknowledges the initial emergency response measures taken by GBS Gold Pty Ltd and the work being undertaken by the Australian Transport Council, the Northern Territory Government and the Australasian Railway Association in regard to initiatives intended to raise public awareness of the safety risks associated with level crossings.

The ATSB report recommends that relevant authorities consider the issues identified by the investigation in relation to the medical examination of heavy vehicle drivers, sighting distance requirements at level crossings used by high combined gross mass vehicles, driver compliance at railway level crossings, and accident response in light of the remoteness of much of the Northern Territory rail corridor.

 

ATSB Preliminary factual report on Boeing 747 electrical system event

An ATSB preliminary factual report into an electrical system failure involving a Boeing 747-400 near Bangkok on 7 January 2008 indicates that the event was less serious than first reported.

The aircraft, with 346 passengers and 19 crew on board, was being operated on a scheduled service between London and Bangkok. When the aircraft was at about 21,000 feet on descent to Bangkok Airport, the customer service manager notified the flight crew that a substantial water leak had occurred in the forward galley. Over the following 12 to 13 minutes, cockpit indications showed a number of electrical bus and system failures that indicated alternating current (AC) buses, 1, 2 and 3 were not powered. The status of AC bus 4 appeared normal and some systems were powered by batteries.

The captains primary flight display, navigation display, and some other instruments were available in a degraded mode and the crew conducted an uneventful approach and landing in day visual meteorological conditions.

Post-flight inspections identified a minor water leak in the forward galley sink drain and that an ice drawer drain was blocked. That inspection also found cracks in a fibreglass drip shield located above an electrical component rack in the aircraft's main equipment centre, as well as evidence of dark liquid stains on the shield. Further inspection found that a ribbon heater on a drain line leading to the forward grey water drain mast was inoperative, and that a length of hose on the drain line at that location was split.

On 11 January 2008, the aircraft manufacturer issued a Multi Operator Message to operators of 747-400 series aircraft, containing advice and instructions for the inspection and repair of main equipment centre drip shields. The manufacturer is preparing an inspection and repair alert service bulletin on the same subject that is scheduled for release by May 2008.

In addition to conducting fleet-wide inspections and, where necessary, repairs to drip shields and drainage systems, the aircraft operator issued a Cabin Standing Order and a Flight Standing Order requiring cabin and flight crews to identify, treat and report abnormal water accumulation in galley areas.

The event involves complex systems and a wide-ranging investigation is continuing with the cooperation and assistance of local and international agencies, the aircraft manufacturer and the operator. Given the complex nature of the investigation, the ATSB is not able to comment further to the text contained in the preliminary report. Provision of analysis and findings in relation to the circumstances of this incident (which may be further revised) will be provided in the final report. In addition, the ATSB will immediately communicate any need for urgent safety action should that become evident during the investigation.

Copies of the report can be downloaded from the ATSBs internet site at www.atsb.gov.au