A Boeing 737 freighter aircraft developed multiple technical issues that the flight crew could not resolve using the approved non-normal checklist procedures, resulting in the crew conducting an emergency descent and diversion during which they experienced separate incapacitation events, an ATSB investigation details.

The 737-376SF aircraft, operated by Express Freighters Australia, was conducting a scheduled freight flight from Brisbane to Melbourne on the evening of 15 August 2018 with two flight crew on board. During cruise the crew observed the master caution warning light flickering, and then identified that the right wing-body overheat annunciator was illuminating.

In response the flight crew actioned the non-normal checklist. When this did not resolve the overheat indication, the crew then conducted further troubleshooting in consultation with line maintenance operations personnel in Sydney.

As the flight progressed towards Narrandera, the crew identified that the cabin pressure was reducing, commenting to each other that they both felt slightly unwell. As the cabin altitude continued to climb and anticipating that it would exceed 10,000 feet, the crew elected to don the emergency oxygen masks and advised air traffic control that they had commenced a descent.

During the initial phases of that descent, the captain became temporarily incapacitated due to ingesting an increased supply of oxygen. This was due to the captain selecting the emergency flow setting while manipulating the oxygen mask settings. The first officer then declared a MAYDAY, advising of issues with the aircraft and that they had commenced an emergency decent. The flight was subsequently diverted to Canberra Airport.

After the captain had recovered, the first officer experienced incapacitating symptoms consistent with hyperventilation. The captain then declared a PAN PAN radio call to air traffic control, informing of the first officer’s incapacitation and requesting the attendance of emergency services on arrival at Canberra. The aircraft was landed without further incident.

The ATSB’s investigation identified that the intermittent flickering of the master caution light and overheat annunciator was likely due to an electrical fault in the right wing-body overheat detection system.

A fault with a valve in the aircraft air conditioning system prevented isolation of the right wing-body duct, which led the crew to conduct further troubleshooting during which the cabin air supply was reduced. In conjunction with a higher than normal cabin leak rate, the reduced airflow also lessened the cabin pressure.

“The flight crew responded to the cabin pressure reduction by donning their oxygen masks and descending the aircraft,” said ATSB Director Transport Safety Stuart Macleod.

“During the descent, the captain selected emergency flow on the oxygen mask resulting in an ingestion of gaseous oxygen, causing their temporary incapacitation.

“After the flight was diverted to Canberra, the first officer then experienced symptoms consistent with hyperventilation, leading the captain to declare the first officer incapacitated.”

After landing, both the captain and first officer were transported to hospital via ambulance for medical assessment. Post‑occurrence medical testing and assessments did not identify lasting effects from the flight.

Separately, the aircraft was inspected by maintenance personnel.

“Maintenance engineers identified a range of serviceability issues with the aircraft fuselage cabin drain valves, fuselage door seal, and the auxiliary power unit duct bellow seal that affected the capacity for the aircraft to hold cabin pressure,” Mr Macleod said.

Subsequent to the occurrence the operator implemented a range of changes to its maintenance program, including incorporating a functional check of the cabin drain valves; specifically verifying the integrity of the auxiliary power unit duct bellows seal; and introducing an enhanced aircraft cabin pressurisation system check.

“This occurrence is a reminder to flight crews of the hazards of dealing with system malfunctions that are not resolved using the approved non-normal checklist procedures,” said Mr Macleod.

“Configuration changes to an aircraft system may induce other effects due to underlying unserviceable components that may not be immediately apparent.”

The investigation also reminds flight crews to be aware that non‑normal situations can lead to a misapplication of emergency equipment in the moment that it is actually needed. In this case the selection of the emergency flow setting on the fixed oxygen system resulted in a temporary incapacitation of the captain.

“A series of non‑normal events, in conjunction with the use of emergency equipment, can add pressure and workload to the flight crew.”

Read the final report: Depressurisation and crew incapacitation Boeing 737-376SF, VH-XMO, 19 km north of Narrandera Airport, New South Wales, on 15 August 2018

Key Points

• While flying after last light in moderate to severe turbulence, the Visual Flight Rules rated pilot likely became spatially disorientated and lost control of the helicopter;
• Research shows that pilots not proficient in instrument flying will become spatially disorientated and lose control within minutes after visual cues are lost;
• A diversion or precautionary landing is almost certainly the safest option if day VFR rated pilots find themselves in a situation where last light is likely to occur before the planned destination is reached.

The collision with water of a Bell UH-1H helicopter near Anna Bay, NSW, resulting in the loss of all five people on board, highlights the significant risk of visual pilots attempting to fly in instrument conditions, the Australian Transport Safety Bureau (ATSB) investigation into the 6 September 2019 accident notes.

The pilot of the UH-1H likely became spatially disorientated and lost control of the helicopter while flying in dark night conditions, the investigation found. Published last light for Anna Bay was 6:01pm, with recorded data showing that the helicopter made a rapidly descending left turn and collided with water at about 6.13pm.

Wreckage of the helicopter was subsequently located in about 30 metres of water, approximately 5 kilometres south-west of Anna Bay, almost three weeks after the accident.

The pilot was only qualified to fly by day under the Visual Flight Rules – VFR – and so was not trained or experienced in maintaining control of the helicopter with sole reference to the flight instruments, the investigation notes.

“The ATSB found that the pilot continued to fly after last light without the appropriate training and qualifications, and then into dark night conditions that provided no visual cues. That significantly reduced the pilot's ability to maintain control of the helicopter, which was not equipped for night flight,” said ATSB Chief Commissioner Greg Hood.

“Once visual references were lost, the pilot likely became spatially disorientated and lost control of the helicopter, resulting in a collision with water.”

The helicopter had departed from Brisbane’s Archerfield Airport on a repositioning flight to Bankstown Airport, in Sydney. After refuelling at Coffs Harbour Airport, the helicopter then departed for Bankstown at 4.48pm, which the investigation determined would have left insufficient time for the helicopter to safely reach its destination before the published last light.

As the flight passed the halfway point and progressed closer to the destination, the pilot may have become increasingly committed to continuing with the original plan.

Consequently, deciding to turn back or divert may have been perceived as increasingly difficult, the investigation notes.

“A pilot’s decision to continue their flight when faced with reducing visual cues may be influenced by self-induced pressure to complete their flight,” Mr Hood said.

Air traffic control (ATC) from the nearby Williamtown Royal Australian Air Force Base had made several radio calls with the helicopter prior to the accident, assisting the pilot with requested altitude changes. During one exchange, the pilot commented to ATC about the turbulent conditions they were experiencing. The controller acknowledged the conditions and made a further offer of assistance should it be required.

Visual cues may have been available to the pilot from ground‑based lighting close to the aircraft’s track as the flight progressed after last light. However, at 6.11pm the helicopter commenced a left turn and departed the VFR coastal route and tracked offshore on what appeared to be a direct track to Bankstown.

As the helicopter flew over a featureless sea with overcast conditions blocking out celestial lighting, the pilot likely lost any remaining visual cues and encountered dark night conditions. Williamtown ATC radar contact with the helicopter was lost about two minutes later.

“Research has shown that pilots not proficient in maintaining control of a helicopter with sole reference to flight instruments will become spatially disorientated and lose control within one to three minutes after visual cues are lost,” Mr Hood said.

“A VFR flight in dark night conditions should only be conducted by a pilot with instrument flying proficiency as there is a significant risk of losing control if attempting to fly visually in such conditions.

"If day VFR‑rated pilots find themselves in a situation where last light is likely to occur before the planned destination is reached, a diversion or precautionary landing is almost certainly the safest option, or ATC may be able to provide assistance with available landing options.”

The investigation also found that the pilot, who was under the care of a non-aviation medical specialist, did not disclose on-going medical treatment for significant health issues to the Civil Aviation Safety Authority (CASA). While not considered to be a contributing factor to the accident, this non-disclosure prevented specialist consideration and management of the ongoing flight safety risk the medical conditions and prescribed medications posed.

“This tragic accident also highlights the importance of aviation medical certificate holders reporting relevant conditions and medications to their Designated Aviation Medical Examiner,” Mr Hood said.

“Pathways exist for managing certain medical conditions that do not preclude a pilot from maintaining an aviation medical certificate.”

Read the final report: Loss of control and collision with water involving Bell UH-1H, VH-UVC, 5 km south-west of Anna Bay, New South Wales, on 6 September 2019

Key points:

• After an unsuccessful action to recover from an unanticipated rapid left yaw during a go-around, the pilot did not have sufficient time to deploy the floats nor conduct a controlled ditching;
• Investigation highlights the importance of applying sustained full opposite pedal if an unanticipated yaw occurs;
• Passengers (particularly in overwater flights in helicopters) need a specific briefing on the location and operation of exit doors.

The Australian Transport Safety Bureau (ATSB) is reminding helicopter operators about the importance of considering skill consolidation processes when transitioning pilots to a new and technically different helicopter type, and to build safety margins into their operations to give pilots the best opportunity to succeed. 

The reminders come following the ATSB’s completion of a systemic investigation into an accident involving a Eurocopter (Airbus Helicopters) EC120B helicopter which collided with the water after the pilot experienced a significant loss of directional (yaw) control during a go-around. The EC120B, registered VH-WII and operated by Whitsunday Air Services, had departed Hamilton Island Airport, Queensland on 21 March 2018 on a charter flight to a pontoon at Hardy Reef, on the Great Barrier Reef, with a pilot and four passengers onboard.

While on a slow approach—to allow several birds to disperse—the pilot yawed the helicopter to the left with the intent to land on one of two positions on the pontoon. This subjected the helicopter to about a 20-knot crosswind from the right. When approximately 7 feet above the pontoon, the pilot noticed a message illuminate on the helicopter’s vehicle engine multifunction display (VEMD) and elected to conduct a go-around.

During the go-around and when about 30–40 feet above the water, the helicopter suddenly and rapidly yawed to the left. After unsuccessful control inputs to recover from the rapid left yaw, and with limited time, the pilot was unable to conduct a controlled ditching and the helicopter collided with water. The helicopter’s emergency pop-out floats were not deployed, and the helicopter almost immediately rolled inverted and rapidly filled with water.

The pilot and two of the three rear-seat passengers evacuated from the helicopter with minor injuries. Although the impact forces were survivable, the other two passengers (seated in the front left and middle rear seats) were unconscious following the impact and did not survive the accident. The helicopter later sank and was unable to be recovered.

“The ATSB’s investigation determined it was likely the pilot experienced a high workload during the final approach to the pontoon and a very high workload during the subsequent go-around,” said ATSB Director Transport Safety Dr Mike Walker.

The investigation found that although none of the possible VEMD messages required immediate action, the pilot considered a go-around to be the best option given the circumstances at the time. During the go-around, after the helicopter started rapidly yawing to the left, it is very likely the pilot did not immediately apply full and sustained right pedal input to counter the rapid left yaw.

In the two weeks prior to the accident, the pilot (with a total of about 1,300 flying hours) had obtained a new type rating to fly the EC120B. While accumulating 11 hours experience in command on the EC120B, the pilot had also flown about 16 hours in another and technically different helicopter type (a Bell 206L3).

“The operator had complied with the regulatory requirements for training and experience for pilots on new helicopter types but had limited processes in place to ensure pilots with minimal time and experience on a new and technically different helicopter type had the opportunity to effectively consolidate their skills required for conducting operations to pontoons,” Dr Walker said.

The EC120B has a clockwise-rotating main rotor and a ‘Fenestron’ shrouded tail rotor system. In 2005, the helicopter’s manufacturer released a service letter to remind pilots that Fenestron tail rotors require significantly more pedal travel than conventional tail rotors when transitioning from forward flight to a hover. A section of that letter stated that pilots needed to be prepared for a significant forward movement of the right foot and that insufficient application of [right] pedal would result in a leftward rotation of the helicopter during the transition to hover.

The ATSB found that the safety margin associated with landing on the pontoon at Hardy Reef was reduced due to a combination of factors, each of which individually was within relevant requirements or limits. These factors included the helicopter being close to the maximum all-up weight; the helicopter’s engine power output being close to the lowest allowable limit; the need to use high power to make a slow approach in order to disperse birds from the pontoon; and the routine approach and landing position on the pontoon requiring the pilot to yaw left into a right crosswind (in a helicopter with a clockwise-rotating main rotor system).

In addition, the investigation also identified safety factors associated with the operator’s use of passenger-volunteered weights for weight and balance calculations, the operator’s system for identifying and briefing passengers with reduced mobility, bird hazard management at the pontoons, and passenger control at pontoons.

“Since this accident, the operator has implemented several additional processes for pilots transferring to new helicopter types and for operations at pontoons,” Dr Walker said.

“This includes pilots conducting only into-wind operations at pontoons until they have obtained 20 hours on type. The operator has also introduced a safety management system, and revised processes for obtaining accurate passenger weights, in addition to several other proactive safety enhancements to its operations.”

In the year following the accident, the helicopter manufacturer released a safety information notice about unanticipated left yaw in helicopters with a clockwise-rotating main rotor system. The notice provided detailed advice regarding the circumstances where unanticipated yaw can occur and the importance of applying full opposite right pedal if it occurs.

The notice also stated that for helicopters with a clockwise-rotating main rotor system, that pilots prefer (as much as possible) yaw manoeuvres to the right, especially in performance-limited conditions.

Dr Walker said this accident, along with many other previous accidents, demonstrates the importance of pilots having helicopter type experience when faced with unfamiliar situations in performance-limited conditions, and to follow the immediate actions specified by the helicopter manufacturer, which typically includes immediately applying full opposite pedal input in the event of a loss of yaw control at low height and airspeed.

“Operators, as part of their safety management processes, should consider skill consolidation during and following the in command under supervision phase and provide as much consolidation as possible to reduce the risk of transitioning to a new aircraft type,” he said.

“This is particularly relevant for types with significant differences to those a pilot has previously flown and for operations with reduced safety margins. Pilots and operators should identify and avoid situations that present potential for loss of yaw control in their helicopter type.

“This could include planning approaches that can be rejected by turning with the torque of the helicopter. For example, if crosswind turns are required when landing, conduct turns to the right in a helicopter with a clockwise-rotating main rotor system.”

The investigation also identified that the passengers were not provided with sufficient instructions on how to operate the emergency exits. The passenger seated next to the rear left sliding door was unable to locate the exit operating handle during the emergency, and as a result the evacuation of passengers was delayed until another passenger was able to open the exit. The nature of the door handle’s design was such that its purpose was not readily apparent, and the placard providing instructions for opening the sliding door did not specify all the actions required to successfully open the door.

“Our investigation emphasises that for helicopter flights over water, given the risk of inversion, capsize and disorientation following a ditching, it is imperative that passenger safety briefings include how to operate the passenger’s seatbelt and the location and operation of the emergency exits,” Dr Walker said.

“Operators and pilots of EC120Bs should ensure that passengers in the rear of the helicopter are specifically briefed about the location of the operating handle and the three actions required to open the rear left sliding exit—which is to pull the handle up, push the door out, and slide the door back.”

Read the final report: Loss of control and collision with water involving Eurocopter EC120B, VH-WII, Hardy Reef, 72 km north-north-east of Hamilton Island Airport, Queensland, on 21 March 2018

Key points:

• An undetected error in the fuel quantity gauges (overreading) resulted in the aircraft departing with insufficient fuel;
• Although the fuel level low annunciators were illuminated, the pilot believed the overreading fuel gauges which indicated sufficient fuel to continue to Broome;
• Fuel exhaustion in both tanks led to both engines losing power, resulting in a forced landing on a highway;
• Reliable fuel quantity cross-checking is essential. 

The forced landing on a highway of a Cessna Conquest aircraft with a pilot and nine passengers on board due to fuel exhaustion highlights the importance of accurate fuel management, an ATSB investigation details. 

The Cessna 441 Conquest had departed Fitzroy Crossing for Broome in Western Australia during the afternoon of 2 March 2018 on the last sector of a four-sector scheduled passenger flight.

During descent, the FUEL LEVEL LOW annunciators illuminated, and the pilot observed that both fuel quantity gauges indicated sufficient fuel remaining and continued flying towards Broome.

Subsequently the right engine began surging, followed by similar surging from the left engine. The right engine then lost power and the pilot conducted the engine failure checklist. 

The pilot declared a MAYDAY and advised air traffic control that, as the left engine was still operating, the aircraft would be able to reach Broome. However, the left engine also lost power and both engines were unable to be restarted.

With both engines not providing power, the pilot assessed that the aircraft would not reach Broome and they tracked to the south towards the Great Northern Highway in the vicinity of Roebuck Plains. The pilot landed the aircraft safely on the highway approximately 21 NM east-south-east of Broome.

ATSB Director Transport Safety Dr Mike Walker said undetected water contamination in the fuel tanks, possibly due to condensation forming in the close-to-empty fuel tanks while the aircraft was sitting in humid conditions following maintenance, resulted in the aircraft’s fuel quantity gauges significantly overreading the level of fuel on board. 

The ATSB investigation was unable to determine how the water contamination was not detected despite different pilots conducting fuel quality checks.

“Accurate fuel management is a critical aspect of safe flight operations and it is important to utilise all available means in order to gain the highest assurance that fuel quantity measurement is accurate,” said Dr Walker. 

“It is essential that a reliable fuel quantity cross-check is adopted, utilising at least two independent methods and a conservative approach.”

The investigation report notes that although the pilot routinely compared indicated versus calculated fuel quantities, and indicated versus flight-planned fuel quantities, the pilot did not routinely conduct two other methods stated in the operator’s procedures for cross-checking fuel quantity gauge indications (the use of the fuel totaliser, and prior to engine shutdown after a flight, switching the fuel boost pumps off and checking whether either of the X-FER PUMP FAIL annunciators would illuminate).

“Although the operator had specified multiple methods of cross-checking fuel quantity gauge indications for its Cessna Conquest fleet, there were limitations in the design, definition and/or application of these methods,” Dr Walker said.

The primary method used (indicated versus calculated fuel) was self-referencing in nature, and not able to detect gradual changes in the reliability of fuel quantity gauge indications.

The operator’s pilots also did not record (and were not required to record) sufficient information on flight logs to enable trends or patterns in fuel quantity gauge indications to be effectively identified, and pilots did not routinely cross-check information from fuel quantity gauge indications with information from the independent fuel totaliser.

The FUEL LEVEL LOW annunciators likely illuminated approximately 30 minutes before the fuel was exhausted in each tank, and when the aircraft was still within range of suitable alternative airports, the investigation notes.

“Pilots are required to fully understand the functionality of the low fuel warning system on their aircraft and treat any warning annunciations as being accurate unless there is overwhelming evidence otherwise,” said Dr Walker.

Following the incident, the operator increased the frequency of fuel quantity comparison checks to a known quantity, specified clearer requirements for determining discrepancies when using fuel totaliser figures, implemented additional fuel management record keeping, and increased the focus on fuel management procedures during training.

Read the final report: Fuel exhaustion and forced landing involving Cessna 441, VH-LBY, 39 km east of Broome Airport, Western Australia, on 2 March 2018

Key points:

• Fatigue was likely exacerbated by mild hypoxia, contributing to the pilot falling asleep;
• Pilots need to monitor their health and wellbeing to ensure they are well rested before flight;
• Continuous use of supplemental oxygen is required when flying above 10,000 ft in unpressurised aircraft.

A pilot who overflew their destination and was unresponsive to air traffic control calls for 40 minutes had fallen asleep due to fatigue likely exacerbated by mild hypoxia from the intermittent use of supplemental oxygen, a new ATSB investigation has found.

The pilot was conducting a ferry flight of a Cessna 208B Caravan aircraft from Cairns, Queensland to Redcliffe on the afternoon of 2 July 2020. While cruising at 10,000 feet the pilot encountered unforecast icing conditions and poor visibility due to cloud and climbed to 11,000 feet and began using the aircraft’s supplemental oxygen system intermittently. (Pilots are required to continuously use supplemental oxygen when flying unpressurised aircraft, such as the Caravan, when flying above 10,000 feet.)

When the aircraft was about 53 km west-north-west of Sunshine Coast Airport, air traffic control (ATC) unsuccessfully attempted to contact the pilot regarding their planned descent into Redcliffe, the investigation notes.

Following repeated calls to the pilot, ATC enlisted the assistance of pilots in nearby aircraft to contact the Caravan pilot, who was seen to overfly Redcliffe and track towards Brisbane.

The pilot of a Royal Flying Doctor Service Beechcraft B200 King Air aircraft departing Brisbane was asked by ATC to intercept and contact the Caravan pilot, but their initial efforts were unsuccessful. The King Air pilot then dipped their wings and approached the Cessna in an attempt to trigger its traffic alert and collision system (TCAS), but the pilot remained unresponsive.

At 5:35 pm, after 40 minutes without contact and when the aircraft was about 111 km south-south-east of the intended destination, the pilot woke and ATC communications were re-established. The pilot was then instructed to land at Gold Coast Airport, where the aircraft landed safely just after 6pm.

“The ATSB found that the pilot was likely experiencing a level of fatigue due to inadequate sleep the night before and leading up to the incident,” ATSB Acting Transport Safety Director, Kerri Hughes, said.

“Further, operating at 11,000 feet with intermittent use of supplemental oxygen likely resulted in the pilot experiencing mild hypoxia. This likely exacerbated the pilot’s existing fatigue and contributed to the pilot falling asleep.”

Ms Hughes said most people generally underestimate their level of fatigue and tend to overestimate their abilities.

“This incident emphasises the importance of pilots monitoring their own health and wellbeing, to ensure that they are well-rested and adequately nourished, especially when conducting single pilot operations.”

Ms Hughes said the investigation carefully considered the role of hypoxia in the incident.

“Although a common symptom of hypoxia is loss of consciousness, it is not typical for someone experiencing hypoxia to regain consciousness, while still operating at the same altitude and without additional oxygen,” she said.

“Therefore, from the information obtained by a medical specialist engaged by the ATSB and from studies conducted on mild hypoxia at moderate altitudes, the ATSB determined that it was unlikely that the pilot had lost consciousness solely due to mild hypoxia.

“Rather, the pilot had fallen asleep likely due to a combination of fatigue and mild hypoxia, possibly exacerbated by dehydration and diet.”

Read the final report: Pilot incapacitation involving Cessna 208B, VH-DQP, near Brisbane Airport, Queensland, on 2 July 2020

Key points

• It was likely the pilot suffered an incapacitating medical event.
• Pilot unintentionally diverted off track, leading to the bucket becoming tangled in the trees and causing the helicopter to collide with terrain.
• Some medical conditions may be undetectable by the normal aviation medical screening process
• Pilots should remain vigilant for symptoms which may be the precursor to a more serious medical event.

An investigation by the Australian Transport Safety Bureau (ATSB) has found the pilot of a fire-bombing helicopter likely suffered an incapacitating medical event while repeatedly water bombing a fire near Ulladulla, New South Wales on the afternoon of 17 August 2018.

The pilot of a Kawasaki Heavy Industries BK117 helicopter, registered VH-JWB, had just filled its slung Bambi Bucket without incident from a dam and departed on a fifth fire-bombing circuit. Shortly after, the helicopter diverted off course contrary to the established flight pattern of the Woodburn fire. The bucket and longline then became caught in trees at the edge of a clearing, causing the helicopter to collide with terrain before coming to rest inverted. The pilot was fatally injured and the helicopter was destroyed.

None of the ground or airborne crews heard any radio transmissions from the helicopter immediately before the accident (during water bombing operations it is standard practice to make a radio call when leaving the circuit for any reason, to inform other airborne assets of the helicopter’s tracking). In the minutes prior to the accident, the pilot responded normally to a NSW Rural Fire Service Air Attack co-ordinator conducting an ‘operations normal’ radio call and did not report any difficulties at that time.

During the investigation, ATSB Transport Safety Investigators did not identify any pre-existing defects with the helicopter that may have contributed to the accident.

“The pilot’s post-mortem identified a focus of acute inflammatory change in the heart muscle, a condition known as lymphocytic myocarditis,” Director Transport Safety, Stuart Macleod said. “This condition is capable of causing sudden impairment or complete incapacitation. The pilot is unlikely to have known they suffered from this condition. There are no risk factors for the development of this condition and it cannot be detected by medical screening.”

The pilot’s post-mortem identified coronary heart disease which is also capable of causing sudden impairment and incapacitation. However, despite the pilot suffering from these two heart-related conditions, there was insufficient evidence to determine if they contributed to the accident.

“Pilots are reminded that some medical conditions may be undetectable by the normal aviation medical screening process and should remain vigilant for any medical symptoms which may be the precursor to a more serious medical event,” Macleod said.

The experienced pilot, with a total flying experience of approximately 7,750 hours (approximately 1,300 hours experience operating the BK117 and in excess of 3,000 hours of longline experience) was known to use an over-the-counter medication for the treatment of hay fever. Although labelled as non-sedating, this medication was not approved by the Civil Aviation Safety Authority for use while conducting flying operations.

“The pilot was known to have been taking this medication for some time, so any adverse effects on the day of the accident were considered unlikely,” Macleod said.

“However, pilots should also exercise caution when using over-the-counter medications as their availability does not mean they are automatically safe for use while conducting aviation activities.”

Due to the inverted nature of the accident and resulting vertical compression of the fuselage, the accident was not considered survivable. However, evidence from the first responders showed the upper torso restraint (UTR) was worn incorrectly at the time of the accident.

“Although on this occasion the accident was unsurvivable, the use of such a shoulder harness restraint generally reduces the likelihood of fatal head injuries,” Macleod said.

“Pilots are reminded to always use UTRs if they are fitted to the aircraft.”

Read the final report: Collision with terrain involving BK117 helicopter, VH-JWB, near Ulladulla, New South Wales, on 17 August 2018

A track worker who heard the whistle of an approaching passenger train and had to remove themselves from the danger zone was placed at risk of being struck by the train due to an unapproved safeworking practice, a new transport safety investigation details.

The track worker was an outer hand signaller helping to implement a Track Work Authority for repairs and maintenance work on the Dora Creek rail bridge, on the main north rail line between Sydney and Newcastle, on 9 May 2020.

As the outer hand signaller prepared to remove a railway track signal (RTS) from the rail line, they heard a train whistle and moved off the line to safety. The train, NSW TrainLink passenger service 283D from Newcastle to Sydney, ran over the RTS (a small device attached to a rail that explodes on impact, designed to attract the attention of train drivers) in response to which the driver applied the emergency brakes. The train came to a stand around 60 metres past the track worker.

The investigation into the incident, undertaken by the Office of Transport Safety Investigations (OTSI), which conducts rail safety investigations in NSW on behalf of the ATSB, found that in applying the Track Work Authority for the worksite, an unapproved practice was implemented. That practice, which was intended to improve train operations, involved the Protection Officer instructing workers to remove the railway track signals used to protect the worksite while trains were closely approaching. This was intended to let the train run unimpeded, but this action placed the outer hand signaller at risk of being struck by the train.

“If protection is removed to allow trains to run unimpeded, then effectively there is no Track Work Authority in place, and this practice put the hand signaller at risk as there was no defined process or method for protecting this worker,” said OTSI Chief Investigator and CEO Dr Natalie Pelham.

“This practice was not part of Sydney Trains’ recognised methodology for using a Track Work Authority.”

Sydney Trains has since committed to amend its Network Rules to reinforce an existing requirement where both the inner and outer protection must be replaced immediately after the passage of each rail traffic movement.

“Network rules and procedures for safeworking on railways have been developed to give direction and instruction to workers in how to safely manage work on track,” said Dr Pelham.

“When practices develop that deviate from the established procedures, care needs to be taken to ensure these practices do not introduce unintended risk.

“Rail safeworking practices should only be implemented as approved by the rail infrastructure manager.”

Read the final report: Near hit with rail worker by passenger train 283D, Dora Creek, New South Wales, on 9 May 2020

Key points:

• Ship was conducting a 3,300 NM passage returning to Hobart on charter to the Australian Antarctic Division;
• Large flames were seen erupting from open louvres of the port engine room’s exhaust casing above deck;
• On-going investigation will examine the origin of the fire and the operation of the ship’s fuel oil transfer system.

The Australian Transport Safety Bureau (ATSB) has released a preliminary report from its ongoing investigation into a fire on board the MPV Everest multirole vessel while on charter to the Australian Antarctic Division.

The report outlines basic factual information including the fire’s sequence of events as established as part of the investigation’s initial evidence collection phase, and does not detail any safety findings or analysis.

On the morning of 5 April, MPV Everest was about 1,075 NM north-east of Mawson station in the Southern Ocean on a north-north-easterly course bound for Hobart, with a crew of 37 and 72 expedition staff on board, the preliminary report details.

The ship was making good 11 knots, with power for propulsion being provided by three of the ship’s six engines – numbers 2 and 3 in the port engine room and number 6 in the starboard (the ship’s two engine rooms each contained two 5,760 kW and one 1,920 kW marine diesel engines).

Shortly before 1100, the ship’s master saw large flames erupting from open louvres in the port engine room’s exhaust casing. In response the master raised the alarm and instructed crew and expedition staff to report to their emergency muster positions.

The preliminary report details subsequent events on board the ship, including the mustering of the crew and expeditioners, the firefighting response, the shutting down of the ship’s port engine room and machinery, the ship’s loss of power, and the subsequent confirmation of the fire’s extinguishment.

Passage resumed at about 1820 after propulsion was restored with two engines in the starboard engine room (with the port engine room and machinery unusable). There were no injuries to anyone on board.

The following day, the ship’s master diverted MPV Everest to Fremantle, where it arrived on 13 April.

The preliminary report notes that during initial inspections of the fire-damaged engine room, the crew observed fuel oil dripping down into it from within the exhaust vent casing above.

Recorded data from the ship’s integrated automation system (IAS) showed a routine transfer to top-up the fuel oil settling tank in the port engine room was started at about 0925 on the morning of the fire, the report details. That data indicates that this tank probably overflowed sometime after 1030. The port fuel oil settling tank’s air vent pipes terminate inside the port engine exhaust casing.

“The ATSB’s investigation will continue to examine the origin and cause of the fire and its development, and the operation of the ship’s fuel oil transfer system, including pumps, piping, alarms and automation,” said ATSB Chief Commissioner Greg Hood.

“Other areas of investigation include the performance of the ship’s firefighting equipment, the effectiveness of the ship’s emergency response, and the efficacy of shipboard communication systems.”

Investigators will also continue to analyse recorded data, including from the ship’s integrated automation system and CCTV, and consider relevant human factors.

Mr Hood noted the preliminary report does not include any safety findings or analysis, which will be detailed in the investigation’s final report to  be released at the conclusion of the investigation.

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

Read the preliminary report: Engine room fire on board MPV Everest, Southern Ocean, on 5 April 2021

Australian Transport Safety Bureau Chief Commissioner Greg Hood has handed over the gavel as the chair of the International Transportation Safety Association (ITSA) after completing an unprecedented two-year term presiding over the international network of the heads of 18 independent transport safety investigation authorities.

During the conclusion of a two-day virtual annual meeting of ITSA member heads this week, Mr Hood officially transitioned the position of ITSA chair to Dr Veli-Pekka Nurmi, Executive Director and Professor at the Safety Investigation Authority Finland.

“Being chair of ITSA for two consecutive years – a first in the association’s history – was a great responsibility and privilege, particularly at a time when the world has been navigating the COVID-19 pandemic and when safe and efficient transport networks were needed like never before,” Mr Hood said.

“I wish Dr Nurmi all the very best as the incoming chair of ITSA for the next 12 months. I would also like to thank all ITSA members for their support during my tenure, and for their well wishes ahead of my retirement next month.”

The mission of ITSA is to improve transport safety in each member country by learning from the experiences of others. The case studies from member countries shared during this week’s annual conference covered a wide range of aviation, rail, marine and infrastructure incidents and accidents, and amplified their findings and safety messaging.

“The use of high fidelity animations to clearly demonstrate ‘what happened’ during an accident sequence and to help influence change by highlighting an investigation’s safety messaging has become more prevalent over recent years in a number of countries, including Australia,” Mr Hood noted.

“Using this form of visual media to help share safety learnings is proving to be very valuable, and will no doubt evolve further in the coming years.”

While international travel restrictions deferred the regular in-person ITSA annual meeting for two years in a row, Mr Hood hopes the ATSB will one day host ITSA members in Australia.

“Due to COVID-19, the ITSA 2020 and 2021 conferences intended to held in Sydney evolved into a virtual experience, which proved to be a valuable platform for sharing safety information and pursuing best practices in independent “no blame” transport safety investigations,” Mr Hood said.

“No doubt, the ITSA conference will have another opportunity to head down under in the future, which will not only afford members the opportunity to witness Australia’s transport safety environment first-hand, but will also allow for many members to experience the beauty of Australia for the first time.”