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

Key points:

• Vertical separation between an A320 and a Jabiru aircraft on intersecting flight paths reduced to approximately 600 ft;
• Pilots of neither aircraft had been able to manage separation from the other aircraft;
• While the available evidence did not support a conclusion that aircraft self-separation in Ballina airspace is unsafe, there is the opportunity to potentially further reduce safety risk;
• New Ballina airspace review, modelling system to consider risks associated with transiting aircraft.

The pilot of a Jabiru recreational aircraft was unaware of the presence of an Airbus A320 before the flight paths of both aircraft inadvertently intersected while flying in non-controlled airspace near Ballina Airport, an Australian Transport Safety Bureau investigation details.

The Jetstar Airways A320, with 2 flight crew, 5 cabin crew and 163 passengers on board, was conducting an approach to land at Ballina while the Jabiru, with a pilot and passenger on board, was tracking to the south-west of Ballina en route to Evans Head when their vertical separation reduced to approximately 600 ft (183 m) as their flight paths intersected, with no observed lateral separation. Both aircraft landed at their destinations without further incident.

The ATSB’s investigation into the 28 November 2020 incident details that the A320 flight crew were unaware of the impending conflict until alerted to the presence of the Jabiru by their aircraft’s traffic collision avoidance system (TCAS).

However, the Jabiru pilot had not set their aircraft's transponder to broadcast altitude data (mode 3C), so the A320’s TCAS was unable to provide its flight crew the necessary information to positively avoid the potential collision.

“The pilot of the Jabiru had not selected their transponder to broadcast altitude information, and did not recall hearing radio broadcasts from the A320 until passing above it,” said ATSB Chief Commissioner Angus Mitchell.

“The A320 flight crew, meanwhile, did not recall hearing the Jabiru’s most recent radio broadcast when it was near Lismore; remained unaware of the Jabiru until receiving the TCAS alert; in the brief time available to them did not attempt to make radio contact with the Jabiru; and only sighted it moments before their flight paths converged.

“Consequently, as the pilots of neither aircraft had been able to manage separation from the other aircraft, the vertical separation between them was influenced by chance alone.”

Airspace surrounding Ballina is non-controlled, that is, aircraft are required to maintain separation through see-and-avoid principles – visually sighting other traffic and monitoring radio transmissions – rather than having separation services provided by air traffic control.

“The airspace surrounding Ballina Airport accommodates a complex mix of aircraft types and operations, and there is a number of other non-controlled airports in close proximity,” said Mr Mitchell.

“The ATSB determined that while the available evidence did not support a conclusion that the present system of aircraft self-separation in Ballina airspace is unsafe, there is the opportunity to potentially further reduce safety risk.”

Measures to further reduce risk might include the increased use of controlled airspace, the increased use of ADS-B aircraft surveillance data, both by air traffic services and in-aircraft, and the identification of any increasing risk through the improved monitoring of the quantity and complexity of aircraft movements in Ballina airspace.

“The ATSB supports systemic enhancements to the overall air traffic system that provide a net overall benefit to safety,” Mr Mitchell said.

The investigation notes that a Civil Aviation Safety Authority 2015 review of the airspace surrounding Ballina determined that a higher airspace classification, such as introducing controlled airspace in the vicinity of and an air traffic control service at Ballina was not appropriate.

However, the ATSB found that that review and periodic risk assessments of the airspace did not consider the risks associated with aircraft transiting through the airspace without taking off or landing at Ballina, as occurred in the investigation occurrence.

CASA has advised the ATSB that its most recent review of Ballina airspace is expected to take into account data for transiting aircraft that had either filed a flight plan or been detected by secondary surveillance radar. In addition, CASA has advised it has also developed an airspace risk modelling system that will have an enhanced capability to consider transiting aircraft. 

Separately, the investigation notes that at the time of the occurrence pilots of aircraft operating within 10 nm of Ballina were required to make positional calls on the common traffic advisory frequency (CTAF). In this occurrence, the two aircraft’s flight paths intersected approximately 12 nm to the south-west of Ballina. However, in January 2021 CASA expanded the Ballina CTAF broadcast area to 15 nm.

In addition, in August 2021 Airservices Australia introduced a surveillance flight information service (SFIS), where an air traffic controller based in the Brisbane Air Traffic Services Centre provides traffic information (but not traffic separation) to aircraft operating within the Ballina 15 nm CTAF broadcast area.

The SFIS replaced a certified air/ground radio service (CA/GRS), which was in operation at the time or the occurrence. The CA/GRS was located at Ballina Airport and provided traffic information (but not traffic separation) to aircraft within the then 10 nm CTAF broadcast area.

Read the final report: Separation occurrence involving Airbus A320-232, VH-VGP and Jabiru J230D, 24-7456, near Ballina Byron Gateway Airport, New South Wales, on 28 November 2020

Key points:

• Q400’s landing gear not retracted until aircraft reached 15,900 ft;
• Aircraft was below the maximum landing gear operating speed but exceeded the maximum altitude at which the landing gear could remain extended, although there was no effect on aircraft serviceability;
• Highly-repetitive, routine tasks may result in pilots developing strong expectations that a task has been completed.

A flight crew’s omission of key calls on take-off and incorrectly completing the after-take-off checklist contributed to a Q400 turboprop airliner’s landing gear not being retracted after take-off, a new Australian Transport Safety Bureau investigation report details.

The QantasLink Bombardier DHC-8-402 (Q400) aircraft had departed Sydney Airport on 12 July 2021 to operate a scheduled passenger service to Albury with two flight crew, two cabin crew and 22 passengers on board.

Due to the relatively light weight of the aircraft and the use of normal take-off power, the flight crew expected an increase in aircraft performance, the investigation notes. The captain recalled being very focused on the correct pitch attitude for take-off and monitoring the airspeed in relation to the flap speed limit.

Later during the climb, the first officer provided the after-take-off public address announcement to the passengers. This call, which is made after passing 10,000 ft or when the aircraft is established in the cruise, also serves to notify the cabin crew that the flight deck is no longer ‘sterile’ (that is, cabin crew are free to contact the flight crew outside of emergency situations).

At that point a cabin crew member contacted the pilots, asking if it was normal for the landing gear to still be extended. The flight crew immediately looked at the landing gear panel and identified that the handle was down with 3 green lights illuminated, indicating that the landing gear was still extended.

After confirming that the aircraft‘s speed was below the maximum landing gear operating speed (of 200 kt), the flight crew retracted the landing gear. However, as the aircraft was at an altitude of about 15,900 ft, this meant the aircraft had exceeded the maximum altitude at which the landing gear could remain extended, of 15,000 ft, although this had no effect on the serviceability of the aircraft.

“The ATSB found that both pilots were heavily focused on aircraft performance after take-off, so the positive rate and subsequent gear-up calls were not made, and neither pilot identified these omissions,” said ATSB Director Transport Safety Dr Michael Walker.

Subsequently, when completing the after-take-off checklist, the pilot monitoring provided the ‘landing gear’ challenge and the pilot flying incorrectly called ‘up, no lights’ in response. Both pilots observed that the 3 green landing gear lights were illuminated but neither recognised that this was problematic for this stage of flight.

“It is likely that both pilots had a strong expectancy that the landing gear had been retracted after take-off, and they probably conducted the after-take-off checklist with a high degree of automaticity, rather than consciously looking for what was required.”

The investigation report notes that the flight crew interpreted increased levels of vibration while airborne as being related to a propeller balance maintenance log entry. In an effort to reduce the noise and vibration, the crew reduced the climb speed. This reduced the abnormal indications and seemingly confirmed that the propeller balance was the source of the problem, and is consistent with the effects of confirmation bias.

Dr Walker said the occurrence demonstrates how diverted attention or focus may result in errors of omission, especially where a task may be reliant on standard verbal cues.

“Highly-repetitive, routine tasks may result in pilots developing strong expectations that a task has been completed, even if it has not been, and make it difficult for pilots to identify an omitted action,” he said.

“Accordingly, it is essential that when flight crews are completing checklists, they focus on confirming that the relevant conditions have been met.”

Dr Walker said the investigation did consider what, if any, impact reduced flying levels and skill degradation due to the COVID-19 pandemic may have had on this occurrence.

“While both pilots met minimum currency requirements, and both had recently undertaken a proficiency check, the first officer had conducted less than one third of their normal amount of flying in the previous 90 days and had not conducted any flights for 11 days prior to the occurrence flight,” he noted.

“Overall, there was insufficient evidence to conclude that the first officer’s reduced flight recency contributed to the procedural errors made by the flight crew. The investigation also noted that the operator was aware of the potential issues associated with reduced flight recency and had introduced measures to mitigate the risk.”

The report also notes the cabin crew displayed a high level of vigilance regarding the aircraft state.

“Their willingness to bring the extended landing gear to the attention of the flight crew allowed the the problem to be identified and for the landing gear to be retracted as soon as possible,” Dr Walker said.

“This highlights the strength of timely communications between crew members.”

Read the final report: Incorrect configuration involving Bombardier DHC-8-402, VH-QOY, near Sydney, New South Wales, on 12 July 2021

Change management and risk assessment processes, and unclear communication of a safety-critical action to train drivers, contributed to the runaway and derailment of a fully-loaded 42,500 tonne, 2.86 km iron ore train in Western Australia’s Pilbara region, an Australian Transport Safety Bureau investigation has concluded.

The final report from the ATSB’s systemic investigation into the 5 November 2018 accident describes the circumstances leading up to the train’s runaway, which culminated in its intentional derailment, resulting in 2 remote locomotives, 245 ore cars and 2 km of track infrastructure being destroyed.

When the train, which was being operated by a single driver on BHP’s Newman to Port Hedland railway, was about 211 km from its destination, an inter-car connector separated, severing trainline communications between the lead locomotive and the ore cars toward the end of the train. This initiated an automated emergency brake application, stopping the train as it approached Garden South, which was on a falling (downhill) grade.

The loss of trainline communications started an in-built 60-minute shut-down feature on the braking system of the affected ore cars, which were now holding the train. 

After reporting the emergency stop and taking a number of procedural steps to protect and secure the train, the driver exited the cab without completing the step of placing the automatic brake handle into the pneumatic emergency position. The driver then commenced the process of applying manual handbrakes to each of the train’s ore cars. 

Sixty minutes after the train stopped, and before the driver was able to secure enough of the ore cars’ handbrakes, the affected car control devices shut down, and the brakes were released on the majority of the ore cars in the train.

The train then began to roll away without the driver on board. 

In the ensuing runaway, the train travelled more than 90 km over approximately 40 minutes, before BHP’s Hedland control intentionally derailed it at a crossover to an adjacent track at Turner South, about 120 km from Port Hedland.

“A train runaway can cause injury or loss of life, and while there were no injuries as a result of this accident, it did carry a significant financial and economic cost,” ATSB Chief Commissioner Angus Mitchell said.

“A certain set of specific circumstances meant not completing a single safety-critical action – placing the automatic brake handle in the pneumatic emergency position – had a significant consequence.

“This safety-critical action relied extensively on the driver’s memory, and the investigation found there were limited processes in place to facilitate or cross-check a driver completing key safety-critical actions.”

The investigation found that BHP did not clearly communicate the importance and reasons for this action to its drivers, reducing the potential for the drivers to correctly recall this action.

The same error had been made on a number of previous occasions by other drivers responding to a similar type of event.

Mr Mitchell said the ATSB considered more broadly why prevention of the runaway was dependent on a single safety-critical action.

“The ATSB’s investigation found that, while integrating a new electronically controlled pneumatic braking (ECPB) system with a number of already complex systems into its iron ore trains, BHP managed this integration at an individual system level, rather than through the application of a structured engineering approach,” Mr Mitchell explained.

Subsequently the operator did not identify and manage significant characteristics of how these systems interacted in response to certain fault conditions.

“As a result, BHP’s trains configured for ECPB operation were potentially vulnerable to a runaway event should a unique combination of events and conditions occur,” Mr Mitchell said.

In addition, the investigation identified that, while BHP’s risk assessment for its rail network identified numerous causes and critical controls for incidents such as runaways, it was broad in scope and had limited focus on the causes and critical controls for a train runaway event.

“Although the operator had identified the need for the safety-critical action in its procedures in April 2017, this risk assessment did not include the procedure for responding to brake pipe emergencies and penalties as a critical control, and it did not test the effectiveness of this procedural control,” Mr Mitchell said.

Following the accident, BHP reviewed the risk management framework associated with rail-mounted equipment interaction, updated the risk assessment, and added additional controls related to potential train runaway events.

It also made changes to its controls by revising the operating instruction for brake pipe emergencies. These included a form for drivers to complete confirming they had cross-checked the actions undertaken in response to a system generated emergency brake application with train control prior to leaving the locomotive cab, and amending the instruction to clearly advise the importance of placing the automatic brake handle in the emergency position.

Given that the train stopped at 0340 and the driver was conducting a series of 7 consecutive night shifts, the ATSB also examined BHP’s processes for managing train driver fatigue.

The ATSB found that the BHP roster patterns for fly-in fly-out train drivers were conducive to result in cumulative sleep restriction and levels of fatigue likely to adversely influence performance on a significant proportion of occasions, and BHP had limited processes in place to ensure that drivers actually obtained sufficient sleep when working these roster patterns. However, based on the available evidence, the ATSB did not conclude that fatigue contributed to the runaway event.

The report notes BHP has commissioned external fatigue experts to undertake a range of evaluation and development activities, and has formed a working group to optimise train driver rosters.

“This investigation highlights that rail transport operators considering changes involving the integration of complex systems should utilise a systems engineering approach to identify hazards and then manage risk to ensure that the railway’s operations remain safe,” Mr Mitchell concluded.

Read the final report: Runaway and derailment of loaded ore train M02712, near the 211 km mark south of Port Hedland, Western Australia, on 5 November 2018

The flight crew of a Saab 340 did not detect the aircraft’s reducing airspeed before its stall warning stick shakers activated, an Australian Transport Safety Bureau investigation details.  

On the afternoon of 6 July 2021, the twin-turboprop Saab 340B, operated by Regional Express, departed Perth for a scheduled passenger flight to Albany, Western Australia, with two flight crew, one cabin crew, and 16 passengers on board. 

During climb, the flight crew were alerted to a fault in the wing de-ice system. After levelling off at 7,000 ft, the crew actioned the relevant abnormal checklist, but were unable to clear the fault. They began a descent from 7,000 ft to 5,000 ft to exit icing conditions, and decided to return to Perth.  

As the aircraft was levelling off at 5,000 ft, air traffic control instructed the flight crew to make a right turn. About 20 seconds into the turn, the aircraft’s stick shakers activated, providing a warning of a potential aerodynamic stall in the form of vibrations and an aural clacker sound. 

“The ATSB’s investigation into this incident found the pilot flying became task saturated due to high workload and did not notice the aircraft’s reducing airspeed, which was also missed by the pilot monitoring due to a focus on other tasks until the stick shaker activated,” said ATSB Director Transport Safety Stuart Macleod. 

Responding to the warning, the first officer, who was pilot flying*, initiated the stall recovery procedure before the captain took control to complete the recovery, and the aircraft returned to Perth without further incident. 

ATSB analysis of the aircraft’s recorded data showed the flight crew had reduced the aircraft’s engine power from 60% torque when flying level at 7,000 ft, to about 15% torque during the descent. However, engine power remained at 15% torque when levelling off and turning at 5,000 ft. 

“In order to maintain level flight at that engine power, the autopilot gradually increased the aircraft’s pitch, which led to a gradual reduction in airspeed,” Mr Macleod said. 

“This airspeed reduction went un-noticed by the flight crew until the increasing pitch reached the level required for one of the Angle of Attack sensors to trigger the stick shaker activation.” 

Mr Macleod noted the crew experienced a high workload in the lead up to the stick shaker activation, including multiple communications with ATC, which issued a series of vectors and requested flight information. 

“During periods of high workload, where there is an increased chance of making errors, flight crews should prioritise monitoring critical flight parameters,” Mr Macleod said. 

“Effective communication can help flight crews recognise a situation when their workload is becoming overwhelming, and consequently better manage the situation – for instance, giving themselves more time to complete the required tasks by discontinuing an approach, or deferring ATC requests appropriately.” 

Following the incident, the operator amended flight crew training simulator sessions and related training material to include flight at minimum manoeuvring speeds – minimum airspeeds that provide a margin above a stall during aircraft manoevring. 

The ATSB also found the alert from the aircraft’s de-ice system, which led the flight crew to return to Perth, was probably due to the right wing inboard de-ice boot delaminating shortly before encountering icing conditions. 

*’Pilot flying’ (PF) and ‘pilot monitoring’ (PM) are procedurally-assigned roles with specifically assigned duties at specific stages of a flight. The PF does most of the flying, except in defined circumstances; such as planning for descent, approach and landing. The PM carries out support duties and monitors the PF’s actions and the aircraft’s flight path. 

Read the final report: Stick shaker activation involving Saab 340B, VH-ZLJ, 30.7 km south-west of Perth Airport, Western Australia, on 6 July 2021