Poor track condition including a short twist defect as well as a higher than specified train speed contributed to the derailment of 11 loaded grain wagons south of Narwonah, north-western New South Wales, on 1 October 2017.

The Pacific National grain train service 8838N, comprising two 81-class locomotives and 23 wagons, was travelling from Nevertire to Manildra on the Australian Rail Track Corporation (ARTC) operated rail network, when the 11 grain wagons located at the rear of the consist derailed. An emergency brake application occurred in response to the uncoupling, which brought the front portion of the train to a stop. There were no injuries but there was substantial damage to nine wagons and track infrastructure. 

A transport safety investigation into the derailment, conducted on behalf of the ATSB by NSW’s Office of Transport Safety Investigation (OTSI), found that maintenance of previously identified track defects near the derailment site was not successful in preventing the defects from re-occurring. The investigation also established that the train crew, comprising a driver and an assistant driver, were operating the train at a speed of approximately 80 km/h, in excess of the 60 km/h limit for that section of track specified by ARTC.

This incident highlights the importance of ensuring that track is free from any defects, and that trains travel at or below the speed specified in the standards.

“The incident highlights the importance of ensuring that track is free of defects that effect safety and that trains travel at or below the speed specified in rail network standards,” said OTSI Chief Executive Office Mick Quinn.

The defects around a rail joint and the train speed contributed to the vertical unloading of the wheels on the 12th wagon, Mr Quinn noted.

 “Train 8838N was travelling at 82 km/h immediately before the derailment, where the specified speed for its axle loading was 60 km/h. It is likely that this increased the risk of derailment,” Mr Quinn said. “Also, if other wagons had travelled frequently over this track at increased speeds, this may have led to a more rapid deterioration of the track.”

Repairing the damaged section of track required the replacement 300 m of rail, fasteners and sleepers and 150 m of new formation.

Since the derailment ARTC made a number of changes to its track maintenance systems and processes, and is continuing with steel and concrete re-sleepering and rail joint removal programs to its network in central and north-western NSW.

Read the final report: Derailment of grain train 8838N, Narwonah, New South Wales, on 1 October 2017

The propellers of a Beech King Air operating a charter flight with one pilot and seven passengers on-board contacted the runway during an attempted landing at Mount Gambier Airport when the aircraft’s landing gear had not extended.

An ATSB investigation into the 8 December 2018 event found that the pilot decided to continue an approach to land shortly after having elected to commence a go-around and retracting the landing gear. The pilot had decided to conduct the go-around as he did not have the runway in sight due to cloud at the minimum descent altitude. 

“After retracting the landing gear, the pilot subsequently sighted the runway and decided to continue the approach, but inadvertently did not re-extend the landing gear,” ATSB Director Transport Safety Stuart Macleod said.

The aircraft touched down with the landing gear retracted, with the propellers contacting the runway.

“As a consequence, the aircraft touched down with the landing gear retracted, with the propellers contacting the runway twice before the pilot initiated a go‑around.”

During the landing attempt both propellers were damaged, with fragments of the left propeller penetrating the left side of the fuselage. The left engine also failed upon the application of power for the go-around, however, the aircraft then landed without further incident.

The pilot and passengers, one of whom was a commercial pilot licence holder seated on the flight deck next to the pilot acting as an observer, were uninjured.

“The pilot's expectation of the landing gear position, possibly coupled with the effects of the now increased workload, probably led to him not detecting the retracted landing gear before the aircraft contacted the runway,” said Mr Macleod.

The ATSB investigation notes the decision to conduct a go-around resulted from the pilot’s misunderstanding of the situation and assessment that a runway overrun was imminent.

“There are hazards associated with spontaneous decision-making, particularly during a high‑workload phase of flight in a complex aircraft,” Mr Macleod said.

“Research on unexpected changes in workload during flight has found that pilots who encounter abnormal or emergency situations experience a higher workload with an increase in the number of errors compared to pilots not experiencing these situations.”

Mr Macleod noted that the pilot and his youngest son sadly lost their lives in a bushfire on Kangaroo Island in January 2020.  

“The ATSB acknowledges the contribution the pilot made to the aviation and outback tourism industries, and thanks his family for their cooperation during the final stages of this investigation during a very difficult time.”

Read the final report: Wheels-up landing involving Beech Aircraft Corporation B200, VH-ODI, Mount Gambier Airport, South Australia, on 8 December 2018

The deployment of an emergency exit’s ditching dam in flight highlights to flight crews that not every system in an aircraft is controllable or monitored, an ATSB investigation reinforces.

The 8 August 2019 incident occurred when a QantasLink Dash 8-300 aircraft was operated on a scheduled passenger flight from Adelaide to Whyalla, South Australia. The flight had proceeded normally until just after top of descent when a loud repetitive banging noise was heard in the cabin.

The two cabin crew members initially suspected the sound was due to ice coming off the propellers and hitting the aircraft fuselage, but the volume and intensity of the noise did not align with their previous experience of flying in icing conditions, and they decided to break the sterile cockpit protocols in place for the descent and landing in order to inform the flight crew of the situation via the interphone.

Further investigation by the cabin crew identified that the noise was coming from the vicinity of the right rear emergency exit at seat row 10. They then identified a yellow object flapping on the outside of the aircraft, just below the exit. The flight crew concluded that the right-hand ditching dam – an inflatable device that activates on operation of the exit hatch after a ditching or landing on water, in order to minimise water ingress into the cabin – had inadvertently deployed. They elected to continue to Whyalla, where an uneventful landing was conducted.

Cabin crew should not hesitate to inform flight crew of abnormal conditions within or external to the cabin.

ATSB Director Transport Safety Stuart Macleod said that the cabin crew had acted appropriately in breaking the sterile cockpit environment – where non-essential activities and communications on the flight deck are not permitted to minimise distraction during safety critical phases of flight – and alerting the flight crew to the situation.

“Not every system in an aircraft is controllable or monitored by the flight crew,” Mr Macleod said.

“Cabin crew should not hesitate to inform flight crew of abnormal conditions within or external to the cabin, as flight crew may be unaware of the situation.”

QantasLink subsequently determined that the ditching dam had not inflated but rather, for reasons that could not be determined, its cover had opened in flight, allowing the uninflated dam bag to unfurl into the slipstream.

The bag, cover and inflation hose then hit the fuselage repeatedly, which was the loud noise heard by the occupants of the aircraft.

“Management of the unexpected deployment was controlled through the use of non‑normal checklists and effective resource management,” Mr Macleod said.

Read the final report: In-flight deployment of ditching dam involving De Havilland Aircraft of Canada DHC-8, VH-SCE, 80 km south-south-east of Whyalla Airport, South Australia, on 8 August 2019

The ATSB is advising Pilatus PC-12 operators to review their pitch trim system training and checking processes to ensure pilots are adequately prepared to manage a trim runaway emergency.

The advice forms part of an ATSB investigation report into a pitch trim runaway and partial loss of control incident experienced by a Royal Flying Doctor Service (RFDS) Pilatus PC-12 aircraft near Merredin, in Western Australia, in April 2019. 

The investigation describes how shortly after midnight and approximately 90 seconds after departing Merredin, the PC-12/47E, with a pilot, flight nurse, doctor and patient on board, was climbing about 1,400 ft above ground level when the Pitch Trim Runaway warnings activated and the aircraft started to nose over.

The pilot initiated the Pitch Trim Runaway emergency procedure from memory but the investigation found that the pilot inadvertently moved the Flap Interrupt switch instead of selecting the Trim Interrupt switch. Both switches are located in close proximity to each other on the PC-12’s centre console, which the investigation found to be a safety issue.

Consequently, the pitch trim runaway continued uninterrupted with full nose-down reached 16 seconds after the warning message activations, with the aircraft pitch attitude moving from +9.5 degrees nose-up down to -7.5 degrees.

As a result of the abnormal trim setting and aircraft airspeed, the nose-down control forces were excessively high. Despite exerting maximum effort with both hands on the control column, the pilot was unable to fully counteract the nose-down force and there were times when the aircraft developed high rates of descent, descending to a minimum height of 400 ft above ground level.  

The ATSB advises PC-12 operators to review their training and checking processes related to the pitch trim system to ensure that pilots are adequately prepared to manage a trim runaway emergency.

The report describes how the pilot continued with the emergency procedure from memory but was unable to resolve the full out-of-trim condition and serious control difficulties. With the assistance of the doctor who pulled on the other control column, the pilot was able to return to Merredin for a flap-less landing. The aircraft was undamaged and the occupants uninjured.

ATSB Executive Director Transport Safety Director Nat Nagy said the cause of the pitch trim runaway was a malfunctioning relay in the manual stabiliser trim system. (At the time of the incident Pilatus was progressing the development of a replacement relay for the manual and autopilot stabiliser trim systems.)

“The ATSB advises PC-12 operators to review their training and checking processes for the aircraft’s pitch trim system to ensure that pilots are adequately prepared to manage a trim runaway emergency,” Mr Nagy said.

“The similarities between the Trim Interrupt and Flap Interrupt switches and their co-location unnecessarily continues to increase the risk of mis-selection and contributed to the excessive out-of-trim condition in this incident”, he noted.

In this incident, after selecting the wrong switch, the pilot pulled the Pitch Trim Circuit Breaker, in line with the checklist, but only after the trim had reached the full nose down position so there was no noticeable change in the controllability of the aircraft.

“More broadly this incident also reminds pilots and operators of all aircraft types to understand the expected system behaviour from switch and other control selections.”

Mr Nagy also reinforced that for flight control emergencies such as out-of-trim conditions, maintaining control of the aircraft while resolving technical issues is imperative.

“A critical consideration for pilots during flight control emergencies is the control of airspeed and engine power,” he said.

“In this incident, as the pitch trim runaway progressed, the reinforcing cycle of increasing control loads, forced descent, and increasing airspeed was initially exacerbated by high engine torque. The airspeed reached 210 kt with an increasing risk of descent into terrain before the pilot reduced engine torque and airspeed to partially alleviate control loads and to arrest the descent.” 

The ATSB found that the emergency procedures and systems information in the PC-12 Pilot Operating Handbook/Airplane Flight Manual and Quick Reference Handbook did not provide effective guidance or sufficient information for pilots contending with a pitch trim runaway.

The investigation also notes that incomplete systems knowledge and unrealistic practice exercises undermined the effectiveness of RFDS training and checking processes for a pitch trim runaway.

Read the report: Pitch trim runaway and partial loss of control involving Pilatus PC-12/47E, VH-OWJ, near Merredin, Western Australia, on 14 April 2019

The derailment of five freight train wagons highlights the importance of robust network rules that provide guidance for degraded condition operations, an ATSB investigation found.

During the 31 March 2019 incident, SCT Logistics freight train 7MB9 was exiting a refuge loop at Goulburn, New South Wales, when the five wagons derailed and obstructed both the Up and Down main lines.

Prior to the derailment, the driver of the train had been authorised to pass a signal at Stop, since the signal could not be cleared due to a track circuit fault. The fault had occurred the evening before, when another train passed through the refuge. At the time, the network controller and the on-call signal electrician had consulted on the problem, and agreed that trains could continue by passing the Stop signal.

A transport safety investigation into the incident, conducted on behalf of the Australian Transport Safety Bureau by NSW’s Office of Transport Safety Investigation (OTSI), found that the wagons had derailed due to a broken rail, which had likely broken under the previous train. The break, which had probably caused the signal to be stuck at Stop, had gone undetected.

Personnel need suitable guidance in assessing when it is safe to continue operating trains, and to judge under what conditions operations can continue safely.

Examination of the track identified that a crack had likely initiated from a lack of weld fusion at the foot of the rail in an aluminothermic junction weld. This defect area was located in a portion of rail not easily detectible through continuous ultrasonic testing and was not detected during routine maintenance.

“It is critical that areas of the rail that cannot be easily inspected during scheduled continuous ultrasonic testing are tested thoroughly at the time of welding to ensure that the weld is free from defects,” OTSI COO and Deputy Chief Investigator Kevin Kitchen said.

The investigation’s findings also noted other factors that increased risk in relation to this occurrence, in particular regarding the network rules in place by rail infrastructure manager ARTC.

“Network rules that permit degraded operations must be assessed to ensure that the application of these rules do not increase risk to an unacceptable level,” Mr Kitchen said.

“Personnel responsible for implementing these rules should have sufficient guidance to assess when it is safe to continue operating trains, or under what conditions operations can continue.”

Read the final report: Derailment of freight train 7MB9, Goulburn, New South Wales, on 31 March 2019

A large crack across the width of a Robinson Helicopter Company R22 helicopter’s main rotor blade demonstrates that unexpected fatigue cracking can occur on critical flight components, and serves as a reminder to pilots and maintainers of the importance of vigilance during pre-flight and daily inspections, an ATSB investigation notes.

The R22 Beta helicopter, registered VH-HPH, was conducting mustering at Labelle Downs Station in the Northern Territory on 16 December 2016 when the pilot noted the onset of vibrations. In response, the pilot successfully conducted a precautionary landing and shut down the helicopter. A subsequent ground inspection revealed a significant crack had progressed almost entirely through the cross-section of a main rotor blade.

“Technical analysis of the main rotor blade at the ATSB’s facilities in Canberra identified that a significant fatigue crack had propagated almost entirely through the blade chord,” said ATSB Director Transport Safety Stuart Macleod. “This led to instability and vibrations of the aerofoil structure during the occurrence flight.”

If main rotor vibration rapidly increases or becomes severe during flight, make an immediate precautionary landing.

The analysis identified that the fatigue crack initiated at the trailing edge bond line and propagated through both the upper and lower blade skins until terminating at the leading edge D-spar.

The ATSB’s investigation was unable to determine conclusively which factors – either individually or in combination – contributed to the crack initiation, but said it was possible a number of variables influenced the initiation of the blade cracking, including the component’s design, manufacture and operation.

“This incident reinforces to helicopter pilots, operators and maintainers that they should be particularly vigilant during the daily or pre-flight inspections,” Mr Macleod said. “Inspections represent important opportunities to detect cracking that may not be obvious. Any form of damage such as paint blistering, denting and corrosion to the main rotor blade surfaces is cause for further investigation.”

Following the occurrence, Robinson issued a safety alert to all R22 operators detailing the crack location and recommended particular attention from pilots and maintainers when visually examining the trailing edges of blades during the daily or pre-flight inspection.

“Robinson warns that if main rotor vibration rapidly increases or becomes severe during flight, make an immediate precautionary landing,” Mr Macleod said. “Do not attempt to continue flight to a convenient destination.”

Mr Macleod noted that during the incident flight, the pilot’s action to land the helicopter prevented further deterioration of the main rotor blade surface and removed the potential for an in-flight blade separation and subsequent loss of control.

Robinson subsequently implemented a minor design change to the A016-6 blade design, extending the length of the trailing edge metal doubler to eliminate potential stress gradients. The revised blade entered production in February 2017.

Separately, the Civil Aviation Safety Authority issued an Airworthiness Bulletin to alert all R22 operators and maintainers to the occurrence, and to provide advice on how to avoid future occurrences.

Read the final report: Main rotor blade crack and precautionary landing involving Robinson R22 Beta, VH-HPH, 12 km south-west of Labelle Downs Station, Northern Territory, on 16 December 2016

A turboprop airliner’s automatic ignition systems performed as designed, successfully relighting the aircraft’s engines after they separately flamed out in heavy rainfall when the aircraft was on descent to land at Canberra Airport, an ATSB investigation has found.

The Virgin Australia ATR72-212A (ATR72-600), registered VH-FVN, was operating a scheduled passenger flight from Sydney to Canberra on 13 December 2018. Due to thunderstorm activity, the pilots were cleared by air traffic control to divert left of their planned track and subsequently held to the south-east of Canberra before tracking south then west to fly around the weather and then tracking back to land.

Shortly after commencing the descent into Canberra, passing 11,000 feet in heavy rain, the aircraft’s right engine flamed out*. The engine’s automatic ignition system engaged and the engine relighted within five seconds without pilot input. Then, approximately one minute later, passing 10,000 feet, the left engine flamed out and it too automatically recovered within five seconds, again without pilot input.

The ATR72’s automatic ignition system worked as designed, correctly detecting the loss of engine power, initiating ignition and successfully relighting the engines without pilot input.

The incident highlights that while engine flameouts are not common in modern turboprop aircraft, they are still possible, according to ATSB Director Transport Safety Dr Stuart Godley.

“The ATR72’s automatic ignition system worked as designed, correctly detecting the loss of engine power, initiating ignition and successfully relighting the engines without pilot input,” Dr Godley said.

After the second engine flameout, the captain selected engine ignition to ‘manual’ in order to provide continuous ignition in an attempt to prevent any further flameouts.

“However, the selection of manual ignition potentially reduces the effectiveness of flameout recoveries, and should only be used when directed by checklists or a minimum equipment lists,” Dr Godley said.

The ATR72’s Pratt & Whitney Canada PW127M engines have a high-energy ignition system which is automatically disengaged following engine start, but in the event of a flameout, will automatically deliver a spark rate of between five and six sparks per second for 25 seconds before reducing to once per second until the engine relights.

Selecting manual ignition would also deliver an initial spark rate of between five and six sparks per second for 25 seconds before reducing to once per second. Consequently, if manual ignition has been ON for more than 25 seconds at the time of a flameout, it would not provide the high initial spark rate of automatic ignition, potentially delaying the relight process.

“This investigation highlights that reliable and effective systems and procedures exist to protect and recover from flameouts and it is important that pilots follow manufacturer procedures,” Dr Godley said.

The investigation noted that ATR’s Flight Crew Operating Manual did not prohibit the use of manual ignition in situations other than where the Electronic Engine Control unit was malfunctioning, and had no explicit direction for ignition to remain set to automatic.

Since the incident, ATR has ensured all operators of the ATR72-600 are aware of the appropriate use of the manual ignition, and is also reviewing operational documentation to determine whether this requirement could be explicitly included.

* A flameout is an unintentional extinguishing of the flame in the engine. This may result from interruption of any of the requirements for sustaining combustion, being fuel, air and heat.

Read the final report: Engine flameouts on descent involving GIE Avions De Transport Regional ATR72-212A, VH-FVN, near Canberra Airport, Australian Capital Territory, on 13 December 2018

A twin-engine Cessna 441 Conquest collided with the ground shortly after take-off following a simulated engine failure at about 400 feet when the aircraft did not achieve the expected single-engine climb performance or target airspeed.

An ATSB investigation into the 30 May 2017 accident, near Renmark, South Australia, which resulted in the deaths of the three pilots on board, found the lack of expected performance was likely due to the method of simulating the engine failure, pilot control inputs or a combination of both. The investigation also established that normal power on both engines was not restored when the expected single engine performance and target airspeed were not attained.

“That was probably because the degraded aircraft performance, or the associated risk, were not recognised by the pilots occupying the control seats,” said ATSB Executive Director Transport Safety Nat Nagy.

“Consequently, about 40 seconds after commencing the simulated engine failure exercise, the aircraft experienced an asymmetric loss of control, and impacted the ground about four kilometres west of Renmark Airport.”

If one engine inoperative training sequences are conducted close to the ground, then effective risk controls need to be in place to prevent a loss of control, as recovery at low height will probably not be possible.

The aircraft, operated by Adelaide-based Rossair, was conducting a check flight on the Cessna 441 for Rossair’s chief pilot by a Civil Aviation Safety Authority (CASA) flight operations inspector (FOI). In turn, the chief pilot was conducting a check of an experienced Cessna 441 pilot who was rejoining Rossair after a period away from the company. The inductee pilot was the pilot flying and was seated in the aircraft’s front left control seat, the chief pilot was seated in the front right seat, and the CASA FOI was observing and assessing the flight from the first passenger seat directly behind the left-hand pilot seat.

They were operating a return flight from Adelaide Airport via Renmark, with a number of flight exercises planned as part of the inductee’s check flight, including the simulated engine failure after take-off on departure from Renmark.

“Conducting the engine failure exercise after the actual take-off meant that there was insufficient height to recover from the loss of control before the aircraft impacted the ground,” said Mr Nagy.

Noting that there is no Cessna Conquest simulator in Australia, the investigation highlights that one engine inoperative training should follow the manufacturer’s guidance and, where it is possible, be conducted in an aircraft simulator.

Mr Nagy said if one engine inoperative (OEI) training sequences are conducted close to the ground, then effective risk controls need to be in place to prevent a loss of control, as recovery at low height will probably not be possible.

“These risk controls can include defined OEI performance criteria that, if not met, require immediate restoration of normal power; use of the appropriate handling techniques to correctly simulate the engine failure and ensuring that aircraft drag is minimised/OEI performance is maximised; and ensuring that the involved pilots have the appropriate recency and skill to conduct the exercise and that any detrimental external factors, such as high workload or pressure, are minimised.”

The investigation also identified a number of safety factors, although they did not necessarily contribute to the accident flight. These included:

• The operator’s training and checking manual procedure for simulating an engine failure in a turboprop aircraft was inappropriate and increased the risk of asymmetric control loss;
• The CASA flying operations inspector was not in a control seat and was unable to share the headset system used by the inductee and chief pilot;
• The inductee and chief pilot, while meeting recency requirements, had limited recent experience in the Cessna 441;
• The chief pilot and other key operational managers within Rossair were experiencing high levels of workload and pressure; and
• CASA’s method of oversighting Rossair increased the risk that organisational issues would not be identified and addressed.

Mr Nagy also noted a lack of recorded data from the aircraft reduced the amount and type of evidence available to investigators about handling aspects and cockpit communications, as the aircraft was not fitted with a cockpit voice recorder or flight data recorder, and nor was it required to be.

“This limited the extent to which potential factors contributing to the accident could be analysed.”

Read the final report: Loss of control and collision with terrain involving Cessna 441, VH-XMJ, 4 km west of Renmark Airport, South Australia, on 30 May 2017

A child fell between a railway station platform and a departing suburban passenger train at Gosnells Station in Perth, highlighting the need to observe platform safety markings, an ATSB investigation into the incident notes.

On 26 October 2019, a Transperth passenger train arrived at platform 2 at Gosnells Railway Station. As passengers left the train, a young child separated from his family when they stopped to look after a sibling. The child walked among passengers as he wandered towards the edge of the platform and the side of the stationary railcar.

As the railcars’ doors closed, after the train driver had viewed the Driver Assist Video monitor to determine passengers had completed boarding and alighting, the child crossed the platform’s painted safety line and neared the edge of the platform. As the child turned and looked back at his family, he stumbled against the side of the train’s third railcar, stepped off the platform, fell between the railcar and platform.  

Family members and those nearby reacted almost immediately and reached between the platform and train to rescue the child as well as alerting onboard passengers. As the train began to move, an onboard passenger, alerted to the situation by those on the platform, used the emergency passenger intercom to contact the driver.

The driver immediately applied full service braking.

While unsure of the exact nature of the emergency, the driver immediately applied full service braking to stop the train. The train soon came to a stop and the family was able to recover the child.

Police reports indicated the child was uninjured; however, a family member was reported to have sustained injuries and was taken to hospital for treatment.

“The ATSB safety message reinforces that passengers at a railway station platform must observe the markings on its surface that specify the required separation from the platform edge,” ATSB Director Transport Safety, Dr Stuart Godley said.

Dr Godley noted that the quick reaction by the driver to stop the train in response to the onboard passenger’s emergency intercom message likely prevented serious injuries to the young child and family members.

Read the final report: Passenger injury at Gosnells Railway Station, Perth, Western Australia, on 26 October 2019