The grounding of a bulk carrier which lost power while transiting a channel from the Port of Weipa highlighted gaps in the port’s risk plans, an ATSB investigation into the incident has found.

On 6 November 2017, the fully laden dry bulk carrier Orient Centaur was transiting the South Channel out of the Port of Weipa, Queensland, under the conduct of harbour pilots as part of a trial introduction of mini cape-size vessels to the port.

Just over an hour after departing from the wharf, the ship’s main engine shut down due to a loss of water from a cracked engine cooling component, and propulsion was lost. Without the ability to steer, the ship grounded on the northern batter of the channel. The stern then slowly swung across the channel and grounded on the southern batter, effectively blocking the channel.

The hazards associated with engine failure had been considered as part of the port’s risk assessment for the introduction of mini cape-sizes, and were to be mitigated by having tugs in attendance. Those hazards had only been considered, however, up to the point at which a ship had entered the South Channel. As a result, on the day of the occurrence, the tugs had been stood down and told to return to the berth after the Orient Centaur was steady in the South Channel.

Now, with the tide falling, there was a significant risk that the ship’s structural integrity would be compromised. The pilots estimated they had about 30 minutes to refloat the ship. A general call was issued to all tugs for assistance.

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Three tugs were mobilised to the assistance of the grounded Orient Centaur and, under the guidance of the harbour pilots, were successfully used to refloat the ship. Orient Centaur was subsequently towed out of the channel to an anchorage.

Surveys conducted over the following days identified that the ship had not sustained any damage.  

ATSB Director of Transport Safety Stuart Macleod said that the incident highlighted the value of comprehensive risk assessments.

“In pre-trial simulations, the risks associated with engine failure during departure were only considered up to when a ship had entered the channel,” Mr Macleod said.

Consequently, the tugs were not in attendance to assist if propulsion was lost. Additionally, the tug masters had not been trained in the specifics of escort towage, nor in emergency response.

“This occurrence highlights the importance of considering potential hazards from end to end in order to provide the best opportunity to manage safety risk,” Mr Macleod said.

In response to the occurrence, the Port of Weipa instituted new practices, with all departing ships over 200 m in length now having an escort tug made fast, from the wharf all the way through to the South Channel exit.

Separately, to address the engine failure issue, the ship’s managers have advised that cooling water is now tested weekly on board the ship, as well as every six months at a shore laboratory. In addition, only manufacturers’ original spares are to be used during maintenance.

Read the final report: Grounding of bulk carrier Orient Centaur, at Weipa, Queensland, on 6 November 2017

The ATSB is highlighting the importance of adhering to standard operating procedures following the release of a final investigation report into the hard landing of an ATR 72 airliner resulting from an unstable approach.

On 10 November 2017, ATR 72-212A VH-FVZ operating as Virgin Australia flight VA646 was arriving at Canberra Airport in conditions of light turbulence. On the flight deck were the captain (who was also a training captain), the first officer (who the captain had previously trained), and a check captain. The check captain was conducting a routine annual operational line check of the captain and a six-month operational line check of the first officer over four flights on the day. The occurrence flight was the last of these flights. In the main cabin were two cabin crew members and 67 passengers.

During the landing approach the first officer, who was the pilot flying, assessed that the aircraft was overshooting the desired approach profile. In response, at a height of 118 feet above the runway, he reduced engine power to idle, but this resulted in an abnormally high descent rate (in turboprop aircraft large propellers spinning rapidly in low pitch create a significant increase in drag).

The aircraft captain, who was the pilot monitoring, identified that power was incorrectly set, and twice called for an increase in power before subsequently intervening and increasing power himself. This intervention, however, occurred too late to arrest the high rate of descent.

Four seconds prior to touching down, the aircraft was descending at a rate of 784 feet/minute, already greater than the design limit of the undercarriage and above the normal descent rate for the approach of about 575 feet per minute. At that time, the aircraft was subjected to a significant change in the wind from a 10 knot headwind component to a 2 knot tailwind component. This resulted in a further loss of lift, and the captain later stated that he felt the aircraft drop out from under him.

Consequently the aircraft reached a recorded 928 feet per minute descent rate at touchdown, resulting in a 2.97 G hard landing on the main landing gear, tail skid and underside of the rear fuselage, resulting in substantial damage.

Unstable approaches continue to be a leading contributor to approach and landing accidents and runway excursions.

The aircraft subsequently required inspection of landing gear components, reskinning of sections of the fuselage underside, and replacement of the tail skid and a drain deflector mast before it could return to service.

“The continuation of the approach when a go-around should have been conducted allowed the subsequent conditions to develop, leading to the hard landing,” ATSB Executive Director Transport Safety Nat Nagy said.

“This occurrence demonstrates the importance of crews adhering to standard operating procedures and conducting a go-around when an approach becomes unstable.

“It also highlights the risks associated with incorrect handling of an approach to land, and the need for prompt and decisive action, as the available time to remedy an unstable approach situation is short.”

Mr Nagy noted that unstable approaches continue to be a leading contributor to approach and landing accidents and runway excursions.

Read the final report: Hard landing involving ATR 72, VH-FVZ, Canberra Airport, Australian Capital Territory, on 19 November 2017

The ATSB has issued safety recommendations to the United States Federal Aviation Administration and engine manufacturer Pratt & Whitney calling for them to maximise a modification that would prevent a component failure of the PW4170 series engine which powers some Airbus A330 airliners.

The recommendations follow an ATSB investigation into a 18 January 2018 incident where a Malaysia Airlines Airbus A330-300, which was operating a scheduled passenger flight from Sydney to Kuala Lumpur, Malaysia, diverted to Alice Springs due to a malfunctioning left engine.

Subsequent disassembly and inspection of the affected engine, a Pratt & Whitney PW4170, identified that, as a result of exposure to elevated temperatures, a segment of the third stage outer transition duct (OTD) had distorted and fractured. The large fractured section caused a blockage within the engine that created turbulent airflow, partially blocking a low pressure turbine vane inlet stage and causing an increase in exhaust gas temperature. That in turn led to low pressure turbine blade failure, high vibration and compressor stall/surge events.

If fleet-wide replacement is implemented, we expect this will have addressed the safety issue.

The ATSB investigation established that there has been a total of 16 similar events globally within the past four years, all attributed to the ‘Advantage 70’ increased thrust modification for the PW4000-100 series engine, including five involving Malaysia Airlines aircraft. The modification increased the engine outer duct gas path temperature, which led to the distortion and liberation of the outer transition duct segments.

Pratt & Whitney, which had ceased production of PW4000-100 series engines for the Airbus A330 in July 2017, has now redesigned the engine’s OTD to withstand higher temperatures. The newly designed hardware will be available for retrofit from this month (November 2019) and service bulletins will recommend installation of the new ducts at the operator’s discretion.

ATSB Director Transport Safety Stuart Macleod said that the ATSB welcomed the availability of the redesigned OTD

“This incident is an example of an engine modification that had undesirable consequences, and Pratt & Whitney has taken timely and significant safety action to redesign the outer transition duct,” Mr Macleod said.

However, the ATSB notes fitment of the ducts is not mandatory.

“We have issued safety recommendations to Pratt & Whitney and to the United States Federal Aviation Administration, urging them to take action to maximise the fitment of the improved components,” Mr Macleod said.

“If fleet-wide replacement is implemented, we expect this will address the safety issue.”

The ATSB is also reminding pilots that, when confronted with significantly abnormal indications, the safest course of action on most occasions is to discontinue the flight as soon as possible

“Recognising that the crew's response to the elevated temperature shortly after take-off was in accordance with the ECAM (electronic centralised aircraft monitoring) procedure, this occurrence highlights that significantly abnormal indications are often symptomatic of a developing problem,” Mr Macleod said.

“In such circumstances, crews should give serious consideration to returning and landing the aircraft rather than continuing with the flight.”

Read the final report: Engine malfunction involving Airbus Industrie A330-323, 9M-MTM, 37 km north of Curtin Airfield, Western Australia, on 18 January 2018

(Source: ATSB)

The ATSB is highlighting the importance of following procedures and applying best practice after two crewmen working aloft on a bulk carrier were seriously injured.

On 11 January 2018, bulk carrier Berge Daisetsu was berthed in Portland, Victoria. A team of six crewmembers were cleaning and painting the cargo hold under the supervision of the chief mate. While the vessel did not have portable scaffolding equipment or approved suspended access platforms for this task, the master discussed other options with the chief mate and bosun for how the upper sections of the hold could be tended to.

The decision was made to jury-rig a portable gangway into a work stage which could then be suspended from the cargo crane hook via slings. The ship’s crewmembers had several discussions, made plans and completed a risk assessment in accordance with the safety management system requirements. However, the equipment and machinery use was contrary to company policy and procedures.

As two crewmembers worked aloft on the platform suspended from the cargo crane, the crane’s block caught on the coaming and suddenly came free, sending an unexpected heavy shock into the platform. The two crewmembers were knocked over by the force of the sudden movement and landed heavily on their knees and lower body, causing serious injury.

The equipment and machinery were not suitable for the task, and their use made hazard identification difficult and exposed the workers to increased risk

The ATSB investigation found that the equipment and machinery were not suitable for the task, making hazard identification difficult, and exposed the workers to increased risk.

“This accident illustrates the consequence of deviating from accepted safety management procedures and industry best practice,” said ATSB Director Transport Safety Stuart Macleod.

“The use of machinery and equipment contrary to its intended purpose, makes hazard identification difficult and exposes those directly involved to significantly increased risk.”

The investigation also found that the fall arrest equipment used was incorrectly attached to the workers on the suspended platform. Consequently, had either of them fallen from the platform, the equipment would not have worked correctly, resulting in serious or fatal injuries.

As a result of this serious incident, Berge Bulk Maritime has completed the supply of approved working aloft equipment to its geared bulk carriers and is progressing modification of vessel cranes for personnel lifting. Specific working aloft and bulk carrier safety training has been conducted and made mandatory for crewmembers every two years.

Read the final report: Serious injury on board Berge Daisetsu, Portland, Victoria, on 11 January 2018

(Source: ATSB)

The ATSB is recommending the Civil Aviation Safety Authority (CASA) publish guidance for the inclusion of safe runway overrun areas at aeroplane landing areas (ALAs).

This formal Safety Recommendation to the aviation regulator stems from the ATSB’s investigation into the fatal accident of a Van’s RV-6A amateur-built aircraft at Somersby, near Gosford NSW, in March 2018. The investigation found an increased risk of occupant injury from a runway excursion at an ALA compared to certified aerodromes.

During landing, the aircraft initially touched down at about the runway’s midpoint at high speed, bounced several times and finally touched down when 125 metres from the runway end. The aircraft over-ran the runway end by 20 metres before impacting the side of a small watercourse, where the aircraft came to a complete stop. The pilot sustained serious injuries in the impact, and succumbed to his injuries two days later. There were no indications of an attempt of a go-around.

As part of the subsequent investigation, the ATSB compared the number of occupant injuries from runway excursions at ALAs with those at certified aerodromes. The analysis found the number of injuries after a runway excursion at an ALA was three times that at a certified aerodrome.

Between 2014 and 2018, there were 99 runway excursion occurrences at ALAs reported to the ATSB. Of these, 10 occurrences resulted in injury (10 per cent), compared with 250 runway excursion occurrences at certified or registered aerodromes, with eight occurrences resulting in injuries (3 per cent).

ALAs are not subject to CASA’s Manual of Standards for aerodromes, which mandates there should be at least an area 30 metres clear at the end of a runway at certified aerodromes to reduce the risk of damage and injury from a runway excursion.  

Instead, CASA’s Guidelines for Aeroplane Landing Areas 92-1(1) outlines considerations for ALA owners relating to obstacle clearance in the proximity of the runway surface area, but contains no specific advice for clear and flat runway overrun areas.

Should a runway excursion occur, obstacles in the overrun area at the end of an ALA runway can increase the risk of injuries to occupants and aircraft damage

“Where possible, ALA owners should consider the inclusion of a runway overrun area,” ATSB Transport Safety Director, Dr Stuart Godley said.

“Should a runway excursion occur at an ALA, obstacles at the end of the runway can increase the risk of occupant injury and aircraft damage.”

As a result of the investigation, the ATSB has issued CASA with a Safety Recommendation to publish guidance for the inclusion of a safe runway overrun area in their advisory publication for ALAs. This publication is a key guidance source for anyone building or maintaining an ALA.

“In this case, the presence of the watercourse at the end of the runway increased the risk of aircraft damage and serious occupant injury as the aircraft stopped significantly faster than it would have if the area had been cleared of obstacles,” Dr Godley said.

Nonetheless, this investigation once again highlights the importance of pilot preparedness to conduct a go-around if the landing criteria are not met or if there are indications of an unstable landing.

“The need for pilots to anticipate, plan and execute go-arounds remains a key safety message from the ATSB for the avoidance of runway excursions,” Dr Godley stressed.

The investigation did not identify any technical issues with the aircraft, including its engine and brakes.

Read the final report: Runway excursion and collision with terrain involving Van's RV-6A, VH-OAJ, Somersby, New South Wales, on 18 March 2018

(Source: ATSB)

The Australian Transport Safety Bureau (ATSB) is recommending that all light aircraft be fitted with upper torso restraints after a fatal passenger charter flight accident raised accident survivability questions.

During the January 2017 accident, one passenger was fatally injured, and two other passengers and the pilot were seriously injured when a Cessna 172 operating a passenger charter flight impacted a Queensland beach after its engine experienced a total power loss at low altitude (read more).

“The aircraft was not fitted with upper torso restraints for the rear passenger seats, which very likely increased the severity of the injuries sustained by the two rear-seat passengers,” ATSB Chief Commissioner Greg Hood stated.

An upper torso restraint (UTR) is a shoulder strap or harness, and when fitted in addition to a lap belt makes an aircraft’s passenger restraint similar to a normal seat belt in a car. UTRs are not required for all passenger seats for small aeroplanes manufactured before December 1986 and helicopters manufactured before September 1992, including those used for passenger transport operations.

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority consider mandating the fitment of upper torso restraints for all seats in small aeroplanes and helicopters.

Although options for retrofitting UTRs are available for a number of models of light aircraft, many of these aircraft manufactured before the applicable dates being used for passenger transport have not yet been retrofitted.

“As a consequence, the ATSB recommends that the Civil Aviation Safety Authority consider mandating the fitment of upper torso restraints for all seats in small aeroplanes and helicopters,” Mr Hood said.

“The recommendation is particularly aimed at those aircraft being used for air transport operations, and where the aircraft manufacturer has issued a mandatory service bulletin to fit UTRs for all seats, or such restraints are readily available and relatively easy to install.”

The ATSB is also issuing a Safety Advisory Notice to all operators of small aircraft and helicopters.

“The ATSB strongly encourages operators and owners of small aeroplanes manufactured before December 1986 and helicopters manufactured before September 1992 to fit upper torso restraints to all seats in their aircraft, if they are not already fitted,” Mr Hood said

The investigation also highlights that there was no requirement for operators of passenger transport flights in aircraft with six or fewer seats to provide passengers with a verbal briefing, or written briefing material, on the brace position for an emergency landing or ditching, even for aircraft without upper torso restraints fitted to all passenger seats.

Further, the investigation also established that the operator did not routinely carry life jackets on its two Cessna 172 aircraft, despite Civil Aviation Order (CAO) 20.11 stating that life jackets are required for all charter flights when ‘in the event of a mishap occurring during the departure or the arrival it is reasonably possible that the aircraft would be forced to land onto water’.

“Accordingly, life jackets were required for the accident flight,” Mr Hood noted.

The report also found that the Civil Aviation Safety Authority’s procedures and guidance for scoping a surveillance event included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.

Read the final report: Collision with terrain following an engine power loss involving Cessna 172M, VH‑WTQ, 12 NM (22 km) north-west of Agnes Water, Queensland, on 10 January 2017

Read the ATSB's safety advisory notice: Upper torso restraints can reduce injuries and save lives. Are they fitted to all seats in your aircraft?

(Source: ATSB)

Pilots should plan to land straight ahead when conducting an emergency landing following an engine failure or power loss at low height, a new ATSB Investigaton reinforces.  

One passenger was fatally injured, and two other passengers and the pilot were seriously injured when a Cessna 172 operating a passenger charter flight suffered a total power loss at a height of about 60 feet while assessing a beach landing area to ensure it was suitable for a planned landing.

After conducting initial engine checks, the pilot had elected to conduct a “significant” left turn to the beach, the investigation into the 10 January 2017 accident at Middle Island, Queensland, established. During the continued turn, the aircraft impacted the beach with little or no control and at a significant descent rate.

Despite a detailed inspection of the engine and related systems, the ATSB was unable to identify the reason for the loss of engine power. Nevertheless, the ATSB found that the operator’s procedures and practices for conducting airborne inspections of the Middle Island aeroplane landing area (ALA) did not effectively manage the risk of an engine failure or power loss when at a low height.

The operator’s inspections were generally flown at 50-100 feet above sea level while flying at normal cruise speed towards an area of water at the end of the beach, with no planned consideration of what to do in the event of an emergency.

Regardless of the reasons why it occurred, an engine failure or power loss should not necessarily lead to very serious consequences, even in a single-engine aircraft.

“This tragic accident reinforces standard pilot training and guidance that, following an engine power loss at a low height, an emergency landing should, in most cases, be planned straight ahead with only small changes in direction to avoid obstructions,” ATSB Chief Commissioner Greg Hood said. 

“Operators and pilots should review their flight procedures to ensure that straight-ahead emergency landings are possible when their aircraft are at a low height. If such landings are not possible, then the suitability of the flight should be evaluated.”

Mr Hood also stressed that operators and pilots that conduct airborne inspections of landing areas should also ensure that the risk of an engine failure or power loss is considered when planning and conducting such inspections at a low height, particularly when below 500 feet.

“Regardless of the reasons why it occurred, an engine power loss should not necessarily lead to catastrophic consequences, even in a single-engine aircraft.”

All options facing the pilot after the power loss were likely to result in at least some level of damage and/or injury, the investigation noted. However, the option likely to result in the least damage or injury was to land the aircraft ahead on the remainder of the beach heading north.

The investigation also found a number of other issues with the operator’s activities, although these were not found to be contributing factors to this accident.

These included under-recording of aircraft flight hours, the aircraft being overweight for the accident flight with baggage and supplies not effectively secured, issues with the operator’s calculations of weight and balance, and the conduct of near-aerobatic manoeuvres during passenger charter flights with limited controls in place to manage the risk of such manoeuvres.

“Broadly speaking, the operator had no effective assurance mechanisms in place to regularly and independently review the suitability of its activities,” Mr Hood said.

The accident also identified a number of issues regarding occupant survivability, including the lack of upper torso restraints (seatbelts) for rear seat passengers, not briefing passengers on the brace position and the non-carriage of life jackets. It also found further scope for the Civil Aviation Safety Authority (CASA) to improve its surveillance activities of small operators.

Read more: ATSB calls for upper torso restraints for all light aircraft  

Read the final report: Collision with terrain following an engine power loss involving Cessna 172M, VH‑WTQ, 12 NM (22 km) north-west of Agnes Water, Queensland, on 10 January 2017

The non-operation of rail level crossing protection following track maintenance highlights the need for formal processes for inhibiting, reinstating and testing rail level crossing protection before rail services resume, an ATSB reports says. 

On the night of 21-22 September 2018, active protection at eight railway level crossings between the Warncoort Loop and Camperdown in regional Victoria was removed to facilitate overnight track maintenance. Active protection was due to be reinstated and the operation of crossing protection equipment tested at each level crossing before the track returned to service the next day.

The next morning, the driver of the Melbourne-to-Warrnambool service noticed the flashing lights for the Hart Street level crossing in Colac were not operating, the investigation report, conducted on behalf of the ATSB by Victoria’s Chief Investigator, Transport Safety, noted.

The driver made an emergency brake application but was unable to stop the train from entering the crossing. Fortunately, there was no road traffic at the time.

A subsequent inspection of the Hart Street crossing found that its active level crossing protection equipment was still inhibited from the previous night’s maintenance work.

Those involved in the activity had only partially restored the crossing protection and the track was returned to service with the Hart Street level crossing protection not operational.

When removing or isolating safety equipment it is important to have formal procedures that require the recording of the isolation, reinstatement and testing to ensure the work is complete

The investigation found that V/Line did not have formal detailed processes for inhibiting, and then reinstating rail level crossing protection equipment.

“When isolating safety equipment, it is important to have formal procedures that require the recording of the equipment’s isolation, reinstatement and testing, in order to validate that restoration work is completed before rail services resume,” the investigation report’s safety message stresses.

Without the benefit of any prescribed procedure there was no process for those doing the work to record and check their actions and ensure correct and complete reinstatement of the level crossing protection.

V/Line has since developed new procedures for inhibiting and reinstating rail level crossing protection, and has reviewed resourcing for similar complex maintenance work.

Read the final report: Non-operation of level crossing protection, at Colac, Victoria, on 22 September 2018

The combination of a wiring error and deterioration of insulation resistance in an uncouple solenoid connector lead to the uncoupling of a suburban passenger train travelling from Flinders Street to Lillydale Station, a new ATSB investigation report says.

Shortly after leaving Croydon Station, the two 3-car train set uncoupled at its mid-point while on a left hand curve, about 800 m from the station. About halfway through the curve the driver noticed the train had uncoupled with the trailing 3-car set detaching from the train. The train, with 150 passengers on board, was travelling at about 78 km/h when it uncoupled with the trailing car set travelling under emergency braking for nearly 200 m before coming to a stop. There were no injuries to passengers or crew. 

The investigation, conducted on behalf of the ATSB by Victoria’s Chief Inspector, Transport Safety, found an undetected wiring error from a modification to the wiring of the low-note whistle of the lead car of the train combined with a deterioration of insulation resistance in the uncouple solenoid resulted in a error circuit forming to energise and trigger the uncoupling. 

The ATSB safety message from this investigation highlights the importance of ensuring a verification program is incorporated into quality assurance systems to mitigate the risk of errors during installation and modification of electrical systems.

This investigation highlights the importance of ensuring a verification program is incorporated into quality assurance systems to mitigate the risk of errors during installation and modification of electrical systems

A function test alone would not have revealed the wiring error; an assurance program involving a secondary and independent check of the wiring modification may have been the only means of detecting the error, the investigation notes.

Following the incident Metro Trains Melbourne inspected found 11 car-sets with low-notes whistles wired incorrectly and rectified the error.  

The ATSB welcomes the updates to the Metro Trains Melbourne’s low-note whistling documentation to prevent further wiring errors and the addition of an independent check of any future wiring work in the form of a supervisor check.

Read the final report: Parting of Metro Trains Melbourne passenger train TD 3817, at Croydon, Victoria, on 9 November 2018