An Airvan aircraft overran the runway on landing after the pilot continued the approach despite being unable to fully extend the flaps and did not apply maximum braking in time after the aircraft landed long.

An ATSB investigation report into the accident details that on 26 December 2021, the Geraldton Air Charter operated GA-8 Airvan was conducting an air-transport flight from Geraldton to East Wallabi Island, off the Mid West coast of WA.

While initially planning for six passengers, the pilot decided to add a seventh from another flight shortly before departure, and later reported this rearrangement resulted in preparations for the flight being rushed.

Earlier in the day, the pilot had flown a Cessna 172 with a personal emergency position indicating radio beacon (EPIRB) device positioned on their right hip.

The pilot knew the EPIRB’s positioning on their right hip could prevent the full extension of the Airvan’s flap lever – which sits to the right of the pilot’s seat – but they forgot to move the EPIRB to their left hip during the rushed flight preparations.

Approaching East Wallabi Island about 30 minutes into the flight, the pilot positioned the aircraft to join the right base leg of the circuit for runway 36, and extended the first stage of flap by moving the flap lever.

“When the pilot turned onto the final leg of the circuit and attempted to select full flap for the landing, the EPIRB obstructed the lever’s movement and prevented it from locking into the full flap position,” ATSB Director Transport Safety Stuart Macleod explained.

Further attempts to select full flap were unsuccessful.

“The investigation notes the pilot did not consider a go around to allow for trouble shooting or repositioning of the EPIRB and continued the approach with just the first stage of flap extended,” said Mr Macleod.

During the landing flare, the aircraft floated more than the pilot expected, and touched down about midway along the runway – almost 300 m beyond the original landing aim point, and about 350 m from the runway’s end.

Mr Macleod noted the reduced drag of the first stage flap setting, possibly combined with a higher than normal approach speed, led to the longer float.

“While a go around should again have been considered at this stage, from the touchdown point it was still possible to stop the aircraft in the remaining runway using maximum braking,” Mr Macleod said.

“However, possibly due to prioritising retracting the flaps after landing, and the pilot not immediately recognising the risk of an overrun, maximum braking was not applied until there was insufficient runway remaining.”

The Airvan overran the runway by about 15 m, resulting in substantial damage to the aircraft, with a main landing gear leg detaching. However, the pilot and passengers were uninjured.

“This accident emphasises the need for careful flight preparation,” Mr Macleod reflected.

“Taking time to confirm that all required actions have been completed prior to departure minimises the chance of in-flight complications.”

Mr Macleod noted the accident also underlines the importance of commencing a missed approach early when an approach and landing deviate from the plan, and a safe landing cannot be assured.

“Pilots should always have a clearly-defined decision point where they can go-around if they’re not confident that a safe landing is achievable,” he said.

“This is especially relevant when landing on shorter runways.”

Read the final report: Runway overrun involving Gippsland Aeronautics GA-8, VH-WSB, East Wallabi Island, Western Australia, on 26 December 2021

Key points:

• Preliminary report details factual information established in the investigation’s early evidence collection phase;
• On-going investigation to consider flight profile, helicopter components, witness accounts, and imagery and video footage;
• Analysis and findings will be outlined in the investigation’s final report.

The ATSB has released a preliminary report from its on-going investigation into a fatal accident involving a UH-1H helicopter during firebombing operations north of Launceston, Tasmania on 14 February 2022.

The crew of an air attack helicopter that was monitoring the Labrina fireground had tasked the UH-1H, registered VH-UHX (UHX), to conduct a water drop on a small hot-spot, the report details. After UHX filled its underslung water bucket at a nearby dam, the air attack crew subsequently observed it conduct a water drop that missed the target, before commencing a gradual left turn and track away from the staging area.

Suspecting UHX’s pilot was encountering an in-flight difficulty, and wanting to avoid any potential conflict with the approaching helicopter, the air attack pilot initiated a climbing 360° turn. After completing the turn the air attack pilot trailed UHX and observed the helicopter descend toward an open paddock where it impacted the ground.

A witness at the staging area, meanwhile, also observed UHX miss the hot-spot when releasing its water load, before it commenced a descending profile, entered a hover and then rapidly yawed twice, before descending from view below the tree line.

The pilot sustained fatal injuries in the accident, and the helicopter was destroyed from impact forces and a fuel-fed fire.

Analysis of the accident site by ATSB transport safety investigators established that the helicopter had impacted the ground along a westerly flight track. Ground scars at the site showed that the tail section made first contact with the ground, followed by the skids, main rotor blades and the cabin.

The helicopter’s tail section, including the tail rotor gearbox, had separated from the fuselage, and had come to rest a short distance from the main wreckage. The bucket and line, meanwhile, had been released from the helicopter prior to the ground impact and were positioned approximately 300 m from the wreckage.

“It is important to note that this preliminary report details factual information established in the investigation’s early evidence collection phase, but it does not detail analysis or findings, which will be outlined in the investigation’s final report,’ ATSB Director Transport Safety Stuart Macleod said.

“As the investigation progresses, the ATSB will continue to analyse the flight profile, further examine helicopter components including the engine, transmission and tail rotor gearbox, consider witness accounts, and analyse accident imagery and video footage.”

The investigation will also give consideration to the helicopter’s performance, maintenance and operational history, emergency procedures, and pilot qualifications, medical history and experience.

Mr Macleod noted a final report will be published at the conclusion of the investigation.

“However, should a critical safety issue be identified at any time during the investigation, the ATSB will immediately notify relevant parties so they can take appropriate and timely safety action.”

Read the preliminary report: Collision with terrain involving Garlick Helicopters UH-1H, VH-UHX, 36 km north of Launceston, Tasmania, on 14 February 2022

A review of search data from the original Australian Transport Safety Bureau-led search for the missing MH370 aircraft has concluded that it is highly unlikely there is an aircraft debris field within the reviewed search area. 

In late January 2022, the ATSB asked Geoscience Australia to undertake a review of some of the sonar imagery collected during the original search for MH370, conducted between October 2014 and January 2017.    

The ATSB made the request after British aerospace engineer Richard Godfrey proposed an impact location for MH370 within an area surveyed during the original ATSB-led search, after his analysis of Weak Signal Propagation Reporter (WSPR) data.    

“The Geoscience Australia report notes that it is highly unlikely that there is an aircraft debris field within the area reviewed,” said ATSB Chief Commissioner Angus Mitchell. 

The review identified 11 objects not analysed during the original search. However, none were assessed to be from an aircraft wreckage debris field.    

Eight of the objects were assessed as most likely geological features, and while three were identified as anthropogenic (ie not naturally occurring), none were determined to be associated with an aircraft. 

Geoscience Australia Chief Executive Officer Dr James Johnson said over a two-month period, a team of experts had reviewed a band of high-resolution sonar imagery spanning 4,900 square kilometres.    

“This data allowed us to detect objects as small as 30 centimetres by 30 centimetres. If the aircraft was within the area we have reviewed, the sonar data would have shown a scatter field of highly reflective debris,” Dr Johnson said.   

“I want to thank my team for the skill and heart they brought to this work and the Australian Transport Safety Bureau for their leadership and partnership throughout this process.”   

Said Mr Mitchell: “The ATSB concluded its formal involvement the search for MH370 in 2017, but we acknowledge the importance of locating the aircraft to provide answers and closure to the families of those who lost loved ones and in the interests of aviation safety. 

“Can I thank Geoscience Australia for their work in applying their expertise and knowledge in reviewing the original search data.” 

Stated Dr Johnson, “We all understand the emotion that will come with this news, and those at the centre of this tragedy remain in our thoughts.”   

The data review report is available for download here.

Media inquiries: media@atsb.gov.au

Key points:

• AW139 rescue helicopter entered an uncommanded descent and lateral drift, coming within an estimated 20 ft of terrain before being recovered by pilot;
• Even for experienced air crews, operations in low-light conditions are challenging;
• Operator is in the process of installing new search lights across their fleet of AW139s, and taken other steps, with the aim of preventing a reoccurrence.

An AW139 rescue helicopter came within an estimated 20 ft of terrain as a result of an uncommanded descent and lateral drift during a 24 July 2020 night-time mission to retrieve bushwalkers from a national park.

The Toll Helicopters-operated AW139 had departed Shellharbour Airport, near Wollongong, NSW, with four crew onboard, comprising a pilot, aircrew officer, paramedic and doctor, tasked to recover two lost bushwalkers from the Bungonia National Park, east of Goulburn.

The flight was conducted under the night visual flight rules with the pilot, aircrew officer and paramedic using night vision goggles.

“On arrival at the search and rescue location, the helicopter tracked over high ground past the edge of an escarpment, where the terrain drops away to a valley floor,” ATSB Director Transport Safety Stuart Macleod explained.

“During the subsequent visual search phase an uncommanded, and increasing, rate of descent and lateral drift developed.”

The aircrew officer, who was in the main cabin by the right door, identified the increasing rate of descent and lateral drift towards a ridgeline and provided corrective instructions to the pilot.

It was estimated that the helicopter came within 20 ft of the ridgeline before the descent and drift were arrested.

Mr Macleod said the ATSB investigation found the pilot’s likely fixation on locating the bushwalkers resulted in them not maintaining an effective scan on the cockpit instruments and outside visual references.

“This resulted in the loss of hover reference and development of an unintended descent and lateral drift.”

In response to the loss of reference the pilot unsuccessfully attempted to engage the helicopter’s auto hover rather than commence an overshoot.

“A subsequent focus on selecting the automated mode further delayed the resumption of the scan and recognition of the increasing descent rate.”

Mr Macleod said radio communications between the paramedic and the ground party hindered communications between the pilot and aircrew officer.

“This inhibited the aircrew officer's ability to verify with the pilot whether the observed initial movement was intentional, preventing recovery from the initial drift and descent.”

In addition, the pilot subsequently did not announce losing hover reference, delaying the aircrew officer’s awareness of the developing situation and support to the pilot.

The ATSB also found the helicopter’s external white lighting (two pilot-steerable landing lights, and a steerable winch and handheld light operated by the aircrew officer) was inadequate.

“At the operating height the external white lighting was inadequate to illuminate the terrain below the helicopter, resulting in the pilot not identifying the developing rate of descent while searching for the bushwalkers.”

As a result of the incident, Toll Helicopters made several changes to their procedures and equipment aiming to prevent a reoccurrence.

These include fitting its AW139s with with a dedicated high-powered search light, amending sterile cockpit procedures, and changes to the operations manual.

The operator has also introduced additional human factors training with a focus on spatial disorientation, confirmation bias and communication techniques for all flight and medical crew.

“Operations at night in low light conditions can be challenging to even the most experienced crews,” Mr Macleod said.

“Low light conditions reduce available visual cues for maintaining aircraft position and undesired aircraft states can develop rapidly.

“To mitigate these risks, crews conducting night operations in such conditions should maintain adequate references, taking into account equipment limitations such as external lighting, and maintain an effective scan to ensure continual awareness of the position and movement of the helicopter.”

Read the final report: Loss of control and near collision with terrain, Leonardo Helicopters AW139, VH-TJO, 25 km east of Goulburn Airport, New South Wales, on 24 July 2020

Key points:

• While flying in the vicinity of a valley, R44 helicopter entered a low-G condition;
• Subsequent extreme teetering and mast bump resulted in the in-flight break-up of the helicopter;
• Investigation highlights that pilots of helicopters with semi-rigid rotor heads must avoid low-G situations.

A Robinson R44 helicopter broke up in flight as a result of extreme teetering, either due to turbulence or inappropriate control inputs, an Australian Transport Safety Bureau investigation has concluded.

A search was launched after the helicopter, flown by a student and instructor pilot, failed to return from a training flight from Goulburn Airport, in the Southern Tablelands region of New South Wales, on the afternoon of 2 December 2020.

Wreckage of the helicopter was found later that evening in the Bungonia State Conservation Area, approximately 31 km east of Goulburn. The accident site was also 4 km north-west of the helicopter’s last recorded ADS-B transmission, which indicated it was descending into a valley.

The helicopter’s engine and fuselage had been exposed to fire, which had self-extinguished before emergency services arrived. Both pilots were fatally injured.

ATSB investigators surveyed the wreckage trail and main wreckage site and, despite fire damage, recovered and examined several components of the helicopter’s main rotor.

Examinations confirmed a mast bump had occurred, and that the helicopter had subsequently broken up in flight.

“Mast bumping is where the inboard end of the main rotor blade contacts the helicopter’s main rotor shaft,” ATSB Director Transport Safety Stuart Macleod explained.  

In R44 helicopters, this can generally be identified by extensive damage to the teeter stops and varying degrees of damage to the main rotor shaft.

“The semi-rigid – or teetering – main rotor design of the R44 and several other popular helicopters relies on rotational force to lift the blades off the droop stops on the rotor hub during flight,” Mr Macleod said.

“During normal operation, the rotor is free to teeter and flap around its designed flight axis via the teeter hinge, while polyurethane teeter stops limit the degree of teetering.”

A mast bump can occur when extreme teetering causes the rotor blades to exceed this allowance, and contact the rotor hub at a high speed.

“The ATSB investigation found that, while flying in the vicinity of the valley, the helicopter entered a low-G condition due to turbulence, inappropriate control inputs, or a combination of both,” Mr Macleod said.

“Low-G conditions can be catastrophic for helicopters with semi-rigid rotor heads. A pilot’s ability to recover from low-G remains uncertain, and would be dependent on airspeed and time available. Pilots must therefore avoid low-G situations.”

Mr Macleod noted pilots should make a careful study of terrain, forecasts and observations applicable to a proposed flight, to identify in advance any significant weather or mechanical turbulence, and avoid flying in these conditions.

“Pilots should avoid flying downwind of hills, ridges or other potential sources of turbulence, particularly during changing or unpredictable weather conditions, and should use slow and small control inputs when encountering turbulence,” Mr Macleod said.

The investigation report also urges operators to consider the benefits of installing recording devices on their helicopters.

“While the fire would likely have prevented data recovery in this case, the inclusion of readily-available cockpit video recorders on helicopters with semi-rigid rotor heads would provide valuable insights into low-G mast bumping events, which could help prevent future occurrences,” Mr Macleod concluded.

Since the occurrence, Robinson has introduced cockpit video/audio recorders as standard equipment on new R44s, having previously been available on the larger R66 models. The recorders are currently optional on the smaller R22s, but will also become standard on these models in 2023, with retrofit kits made available.

Read the final report: In-flight break-up involving Robinson R44 Raven I, VH-HGU, 31 km east of Goulburn Airport, New South Wales, on 2 December 2020

The driver of a road-train truck had been distracted by reaffixing their mobile phone mount to their vehicle’s windscreen before the truck entered an active level crossing and collided with a freight train, an Australian Transport Safety Bureau investigation has found.

The road-train, comprising a prime mover and 3 tipper trailers, entered the Yarri Road, Parkeston level crossing in front of an Aurizon freight train, north-east of Kalgoorlie, Western Australia, on 22 February 2021.

The two train crew (a driver and tutor driver) sustained serious injuries in the subsequent collision. Both the truck and locomotive were substantially damaged, with the locomotive derailing and coming to a rest about 40 m from the impact point. The truck driver was shaken, but otherwise uninjured.

“Approaching the Yarri Road level crossing from the south, drivers need to look ahead and across a curve to see the active crossing lights,” ATSB Director Transport Safety Dr Michael Walker said.

“Because of the effects of distraction, the truck driver was probably only looking at the section of road directly ahead of their vehicle, contributing to them not identifying the flashing lights until it was too late to stop.”

While approaching the crossing, the truck driver was reattaching a dash-mounted mobile phone cradle, and placing a mobile phone in the cradle.

Consequently, the truck driver’s attention was diverted from the road ahead for critical periods of the approach to the level crossing where the flashing light level crossing controls were visible and there was sufficient distance to stop.

“The Yarri Road level crossing design was consistent with the applicable Australian standard and provided sufficient opportunity for attentive drivers to identify the flashing light level crossing controls and stop,” said Dr Walker.

The investigation notes the truck driver was familiar with the route, but had never encountered a train at that level crossing, meaning a low expectancy of encountering a train possibly contributed to the truck driver allocating a low level of attention to the crossing.

The truck driver only noticed the flashing lights, indicating the oncoming train, when it was too late to prevent the collision. When the train crew saw the truck and identified that it was not going to stop for the crossing, it was too late for them to stop their train or reduce the severity of the impact.

“Given the size and weight of most trains, the onus to take action to avoid a level crossing collision rests almost entirely on the road vehicle user,” Dr Walker said.

“Distraction can significantly impair driving safety,” Dr Walker continued.

“Even though it may be possible to occasionally glance at the road ahead while engaged in another task, critical information from the broader road environment may not be effectively perceived and comprehended, particularly on curved road approaches to level crossings.”

There were 11 collisions between heavy road vehicles and trains at level crossings across Australia between July 2020 and June 2021, and 23 such collisions over the previous 5 years.

“Accordingly, in 2021, the ATSB commenced a safety study into level crossing collisions involving trains and heavy road vehicles in Australia,” Dr Walker said.

“The study, which is on-going, includes a review of previous collisions to determine their characteristics and circumstances, and also determine if there are any unidentified systemic safety issues or learning opportunities that could enhance the safety of future transport operations.”

Read the final report: Level crossing collision between freight train 2C74 and road-train truck, Yarri Road, Parkeston, Western Australia, on 22 February 2021

A loaded coal train collided with the rear of a stationary train in low-light conditions at the Port of Newcastle, after network control was not advised that the second train was disabled, a transport safety investigation report notes.

Just after 5 am on 29 July 2020, a loaded Pacific National (PN) coal train collided at 16 km/h with the rear of a stationary One Rail Australia (ORA) coal train, when arriving at Kooragang Coal Terminal, in Newcastle, NSW.

The PN locomotive and the two rearmost wagons of the ORA train derailed in the collision, and came into contact with two adjacent stationary trains, which sustained minor damage.

One of the PN drivers sustained minor injuries, and there was substantial damage to the rail infrastructure.

An investigation into the incident was undertaken by the Office of Transport Safety Investigations (OTSI), which conducts rail safety investigations in NSW on behalf of the Australian Transport Safety Bureau.

The investigation found that while the ORA train was unloading several penalty brake applications associated with a fault in its electronic pneumatic brake system had disabled the train, bringing it to a standstill.

The crew investigated the faults using a series of technical exercises, which caused the train’s End of Train light to be extinguished.

“This disablement of the ORA train constituted a Condition Affecting the Network, but the crew did not report this to the Kooragang Network Controller as they were required to do,” OTSI Chief Investigator Dr Natalie Pelham explained.

“Subsequently, the Kooragang Network Controller set a signal for the PN train to proceed with caution along the arrival road where the ORA train was stationary.”

The terminal area where the accident occurred was poorly lit by artificial trackside lighting, and the absence of an End of Train light at the rear of the stationary train reduced its conspicuity, Dr Pelham explained.

“Light produced by an overhead gantry, above the accident site, may also have caused disabling glare for the drivers of the PN train,” she added.

Since the collision, PN issued notices informing drivers to not exceed 8 km/h upon receiving a shunt proceed signal within Kooragang terminal.

ORA has added programmed monitoring of End of Train lights into its asset management plan, and circulated safety information to their drivers to remind them of the requirement to communicate all conditions affecting the network to network control.

The Australian Rail Track Corporation (ARTC) provided clarification advice to rail operators on the operation of trains with defective EOT lights and updated information contained in the Rail Access Standard (general information). ARTC also plans to review the Kooragang Operations Protocol and conduct a risk assessment to ensure the risk of collision is effectively managed and controlled during operations.

“This accident highlights the importance of train crews communicating conditions affecting the network to network control,” Dr Pelham said.

“It also emphasises the need for train crews operating in areas of restricted visibility to be prepared to stop short of any obstruction on the track.”

Read the final report: Collision between coal trains MB526 and AH378, Kooragang, New South Wales, on 29 July 2020

Key points:

• Aircraft lost engine power and aerodynamically stalled at an altitude insufficient for recovery;
• The use of a damaged engine oil cooler fitting most likely resulted in the engine being starved of oil;
• Accident highlights the complexities of managing partial power loss.

The ATSB’s investigation into a fatal accident involving an Osprey 2 aircraft at Maitland Airport, NSW highlights both the complex nature of managing a partial power loss and the importance of good engineering practices for amateur built aircraft.

The aircraft, built by private builders from plans under the provisions of the amateur-built experimental aircraft system, took off from Maitland Airport on 17 May 2020 for the pilot’s second test flight in the aircraft.

While passing through 2,400 ft, the pilot was advised via radio that the aircraft’s engine was producing white smoke. The pilot noted the engine was not running smoothly.

The pilot broadcast their intention to return to land on runway 23, but during descent turned to join the reciprocal runway 05.

As the aircraft turned onto the base leg of the circuit, the engine failed completely, and the pilot attempted to conduct a forced landing on the closer runway 08.

“During the final stage of the glide approach, the aircraft was observed to abruptly roll, pitch down and collide with the ground,” ATSB Director Transport Safety Stuart Macleod said.

The pilot was fatally injured, and the aircraft was destroyed.

Video from the cockpit showed the airspeed decreased to between 60–65 kt prior to the roll, and examination of the accident site confirmed the aircraft contacted the ground with low forward airspeed while rolling to the left, consistent with an aerodynamic stall.

The ATSB found the use of a damaged engine oil cooler fitting, which was not compatible with the fitted oil hose, most likely resulted in the hose disconnecting from the oil cooler during the climb and the engine’s loss of oil.

“A partial loss of engine power event of this kind is a more complex scenario for a pilot to face than complete engine power loss,” Mr Macleod said.

“Pilots can be strongly influenced by the fact the engine is still providing some power, and often by the strong desire to return the aircraft to the runway to avoid damaging the aircraft in a forced landing,” he explained.

“In this case the pilot’s decision to change from runway 23 to runway 05 meant the aircraft needed to stay airborne longer, necessitating more power from the damaged engine to maintain height.”

The ATSB found this extended airborne duration, and need for increased engine power, resulted in the engine failing due to oil starvation.

“Pilots are reminded that a partial engine failure often precedes a complete loss of power,” Mr Macleod continued.

“In the event of a partial loss of power, the aircraft should be landed at the earliest possible opportunity and consideration should be given to forced landing options along the flight path.”

The investigation also identified that the required, and the majority of the recommended, build inspections of the aircraft were not conducted, and this was not detected prior to the issuance of a certificate of airworthiness that permitted the aircraft to be flown.

“While these inspections would probably not have detected the damaged oil cooler fitting, they may have identified the oil supply hose was in poor condition,” Mr Macleod said.

“They would also have been an opportunity to identify and improve the overall build quality of the aircraft.”

The ATSB also identified a number of other deficiencies relating to the inspection and flight testing of amateur-built aircraft, including the risk assessment of the proposed test pilot.

“This accident also highlights the importance of adhering to the design specifications and good engineering practices when building an amateur-built experimental aircraft,” Mr Macleod said.

“Attention should be given to the component manufacturer’s specifications, installation instructions and limitations to ensure the component, and consequently the aircraft, will perform as intended.”

The ATSB notes the Civil Aviation Safety Authority (CASA)’s proposed Part 43 regulation includes new guidance for amateur-built aircraft(Opens in a new tab/window), to revise the current rules, which were last updated in September 2000.

Read the final report: Collision with terrain involving amateur-built Osprey 2 amphibian aircraft, VH-WID, near Maitland Airport, New South Wales, on 17 May 2020

Key points:

• Pilot was asked to carry out previously-unplanned mustering of cattle to a yard;
• Hazards at the yard likely not identified as pilot did not conduct a new risk assessment including an aerial inspection;
• During a turn the helicopter struck an unmarked single wire earth return line, lost control and collided with terrain.

Mustering pilots are reminded to conduct a new risk assessment before commencing unplanned tasks, an ATSB investigation into a May 2021 wirestrike accident highlights.
 
After two days of wild goat mustering at a property near Hay, New South Wales, the pilot of a Robinson R22 helicopter was instructed to locate a small cattle herd and direct a stockperson to them for mustering to the property’s main yards.

This was first time the main yards were used during the muster. While looking for the herd, the pilot detected a second larger herd and directed the stockperson to the larger herd before heading to locate and move the small herd to the main yards.

After locating the original cattle herd, the pilot began moving them along a fence line towards the main yard and flew ahead and landed to open a gate at the entrance to the yard. They then took-off and flew in a southerly direction—at a height of between 5-10 metres—to another gate that needed to be opened for the cattle. As the R22 turned towards an adjacent gate the helicopter struck an unmarked single wire earth return (SWER) line running across the northern side of the main yards.

Witnesses reported hearing a loud bang, and the helicopter was found on its right side just outside the fence at the north-west corner of the main yards. The helicopter was substantially damaged, with indications it had sustained a wirestrike. The pilot sustained fatal injuries.

“Mustering operations around yards and buildings are inherently dangerous due to low-level hazards including powerlines,” said ATSB Director Transport Safety Stuart Macleod.

“To mitigate the risk of powerlines pilots are reminded that any change to their existing flight or work plan they should conduct a new risk assessment including an aerial inspection to identify potential hazards.”

Powerlines, particularly unmarked wires, can be nearly impossible to see due to the size of the wire, camouflage with the background and the natural limitations of the eye.

“The Aerial Application Association of Australia has been working with landowners and energy suppliers to install markers on powerlines through the Powerline Safety Program. In addition, a number of power companies are making these markers available at reduced cost,” said Mr Macleod. 

The ATSB also found the helicopter’s emergency locator transmitter (ELT) did not activate after the accident as it was selected to OFF.

 “As the accident was witnessed, this did not affect the response, however, having a working ELT increases the likelihood that an aircraft and its occupants will be located quickly in the event of an accident.”

Read the final report: Wirestrike and collision with terrain involving Robinson R22, VH-KLY, 75 km west-north-west of Hay, New South Wales, on 26 May 2021

For more information on how to get powerline markers visit the Aerial Application Association of Australia’s website(Opens in a new tab/window).

Key points:

• A New Generation Rollingstock (NGR) train left a station when the departure signal was displaying a stop indication, resulting in a near collision with another suburban passenger train, which was proceeding in the same direction on an adjacent line to a merging conflict point
• Queensland Rail’s application of risk and change management processes were limited regarding station dispatch procedures associated with the rollout of NGRs
• Change management relating to the moving or installation of signal aspect indicators, to facilitate the NGR rollout, did not provide sufficient detail to ensure consistent and conspicuous placement on platforms.

Risk and change management limitations associated with the rollout of new trains in South East Queensland contributed to a near collision in Brisbane in 2019, an Australian Transport Safety Bureau investigation report notes.

On 25 March 2019, passenger train DW17 left Park Road Station when the departure signal was displaying a stop indication.

The New Generation Rollingstock (NGR) train with a driver, guard, and 41 passengers on board, exceeded its authority by 305 m and travelled through a merging conflict point. The merger point was being approached by a second train, which stopped short when that train’s crew detected the problem.

This was the first of six ‘start against signal’ SPADs involving NGR trains on Queensland Rail (QR)’s Citytrain network between March 2019 and April 2021.

A systemic investigation by the ATSB found limitations in QR’s change and risk management processes, specifically in relation to dispatch procedures involving platform staff and NGR train guards, increased the risk of such SPADs taking place.

“Prior to the rollout of NGR trains, there were five stations – three CBD and two suburban stations – where platform staff were required to provide an ‘allright’ signal to a train guard before the train could proceed,” ATSB Director Transport Safety Dr Michael Walker explained.

“Although platform staff at these locations were trained not to look at the departure signal prior to giving the ‘allright’ signal, as this was not their role, in practice platform staff were checking for the departure signal to be at proceed before giving this signal to train guards, creating the expectancy that the ‘allright’ signal was a reliable indication the departure signal was at proceed.”

The positioning of the guard at the rear of the NGR fleet is unique to the Citytrain network. This meant when the NGRs began operating in late 2017, platform staff were required at other suburban stations to assist passengers accessing the middle carriages, which are designated for disabled access.

In January 2019, QR amended its dispatch procedures to require platform staff at all suburban stations to issue the ‘allright’ signal for all NGR train departures, rather than just those with passengers who required assistance.

“Because the platform staff at these suburban stations followed procedure, and did not follow the informal practice of checking the status of the departure signal, train guards were now much more likely to receive an ‘allright’ signal while the departure signal was at stop,” Dr Walker explained.

“Multiple QR risk management and change management processes did not effectively consider the risk of this taking place.”

The final risk control in place to avoid SPADs under QR’s ‘stopped at red’ procedure was for the driver to check the departure signal after receiving the ‘rightaway’ signal (two bells) from the train guard.

The train guard was to provide rightaway to the driver after checking that the platform departure signal was at proceed – either by observing the aspect in the departure signal, or a signal aspect indicator (SAI) located on the platform if the departure signal was not visible by the guard.

“In this near collision occurrence, when the driver received the rightaway signal from the guard, they had a very high level of expectancy that this meant the departure signal was at proceed, and subsequently the train promptly departed the station platform and passed the signal while it displayed a stop indication,” Dr Walker said.

“Similarly, the guard incorrectly provided the rightaway signal to the driver based on a very high level of expectancy that the ‘allright’ signal, provided by platform staff, also meant the signal was at proceed.”

The ATSB noted that the same basic sequence then happened in another five start against signal SPADs at suburban station platforms involving NGR trains. The departure signal was at stop, the station staff correctly gave the allright signal to the guard when platform duties were complete, the guard incorrectly provided the rightaway signal to the driver while the departure signal was still at stop, and the driver then departed the platform without effectively checking and confirming the departure signal.

Dr Walker said operators should apply a formal change management process to assess the potential risk of a procedural change before determining that the change is minor in nature.

“Operators also should ensure they understand the undocumented or informal risk controls that are in place in their operation, and how exactly operational personnel are applying current procedures, prior to introducing changes,” he said.

“A commonly-overlooked aspect of risk management is the need to consistently monitor and review the health of risk controls, either existing or newly-introduced, through a variety of activities and to continuously look for opportunities to improve the operator’s risk position.”

Signal aspect indicators (SAIs) were installed on station platforms when a guard could not see the departure signal from their normal location. The rollout of the NGR trains meant a number of SAIs had to be installed or moved at platforms around the network, to account for the relocation of the train guard from the middle of the train on traditional type suburban passenger trains to the rear of the the train with the introduction of NGR services.

“QR’s process for installing the SAIs did not provide sufficient detail to ensure consistent and conspicuous placement of them at station platforms,” Dr Walker said. “This increased the risk that an SAI would not be correctly perceived by a train guard.”

The ATSB notes the rate of ‘start against signal’ SPADs has decreased in recent times, as guards become more familiar with the location of SAIs, and the new processes at suburban station platforms.

“The ATSB will continue to examine change management issues in current and future investigations,” Dr Walker concluded.

Finally, although not a contributing factor, the investigation found that a late-notice roster change meant the guard was probably experiencing a level of fatigue known to adversely influence performance.

As a result, QR issued an important safety notice to rail traffic crew and rostering personnel regarding unplanned shifts and required that rostering personnel complete a checklist when arranging unplanned shifts with less than 12 hours prior notice.

Read the final report: Signal DP29 passed at danger involving suburban passenger train DW17 and near collision with another suburban passenger train, Park Road Station, Queensland, on 25 March 2019