Key points:

• Biplane aerobatic aircraft sustained an in-flight break-up shortly after departure from Caboolture;
• Preliminary technical examination determined that two of the eye bolts that attached the upper wings to their supporting struts had failed due to fatigue cracking;
• ATSB has issued a Safety Advisory Notice to other owners and operators of the Acroduster aircraft type to raise awareness of the fatigue cracking.

Technical examinations as part of the Australian Transport Safety Bureau’s on-going investigation into the in-flight break-up of an Acroduster aerobatic biplane near Bribie Island on 18 August have determined that two eye bolts used to secure the aircraft’s upper wings had failed due to fatigue cracking.

The two-seat home-built Acroduster aerobatic aircraft had departed Caboolture on the morning of 18 August to conduct an aerobatic flight with the pilot, the sole occupant, on board.

A short time later the crew of a helicopter operating nearby noticed red and white debris falling from the sky before sighting the main wreckage of the biplane inverted in tidal wetlands in the Pumicestone Passage, adjacent to Bribie Island. The pilot was found to have been fatally injured.

Investigators from the ATSB’s Brisbane office deployed to the site later that day.

“It was evident to our investigators once they had arrived on site that the aircraft had sustained an in-flight break-up, with the wreckage trail distributed over a distance of about 2.4 km,” said ATSB Chief Commissioner Angus Mitchell.

The main wreckage consisted of the fuselage and tail as well as the outer-wing sections, which had remained attached to the fuselage by bracing wires. The remainder of the wing sections had separated from the aircraft.

The aircraft was recovered from the accident site by barge and taken to a secure facility for a detailed examination.

“Preliminary examination of the main wreckage revealed that two of the eye bolts that attached the upper wings to their supporting struts had failed due to fatigue cracking,” said Mr Mitchell.

The ATSB has already notified the owner of the only other Acroduster in Australia of the issue, and has advised its counterpart agency in the US, the National Transportation Safety Board, so that the information can be shared with the US Federal Aviation Administration, the US Experimental Aircraft Association and the kit plane design/material provider.

Additionally, the ATSB has also now issued a Safety Advisory Notice to alert pilots, owners and maintainers of the Stolp Acroduster (both the SA-700 Acroduster and SA-750 Acroduster) to check the condition of their aircraft.

“While our investigation is on-going, the Safety Advisory Notice serves to inform operators of this type internationally of this discovery so that they can take appropriate action to ensure that their aircraft remain airworthy,” said Mr Mitchell.

It is not clear how many aircraft may be affected by the Safety Advisory Notice, however approximately 130 Acroduster aircraft have been built since plans for the types were made available in the early 1970s.  

The accident aircraft, registered VH-YEL, had been built in the United States from plans supplied in 1976 and first flew in 1981. The aircraft was shipped to Australia in 2003 and had accumulated 717 flight hours at the time of the accident.

Mr Mitchell noted today’s preliminary report details basic factual information determined in the investigation’s early evidence collection phase.

“As the ATSB’s investigation progresses, transport safety investigators will undertake a metallurgical examination of the entire upper-wing attachment hardware and structure; review the aircraft’s operational history and maintenance procedures and inspection requirements; and further analyse radar data,” he said.

A final report, which will detail analysis and findings, will be released at the conclusion of the investigation.

Read the preliminary report: In-flight break-up, Stolp Acroduster II SA-750, VH-YEL, 16 km north-east of Caboolture airfield, Queensland, on 18 August 2021

Read the Safety Advisory Notice: AO-2021-032-SAN-001: Are your wing attachment points serviceable?

The forced landing of a turbine-powered Cessna 210 about 560 metres short of the runway threshold following an engine failure from flight in icing conditions highlights the importance of proper pre-flight planning, according to an ATSB investigation.

The US-registered Cessna P210N Silver Eagle, a pressurised Cessna P210N re-engined with a Rolls-Royce M250 turbine, had departed Sydney’s Bankstown Airport for a private flight under instrument flight rules to Hobart’s Cambridge Airport on 19 December 2019. The pilot and a single passenger were onboard.

The flight was planned and conducted through forecast icing conditions although the aircraft was not certified or equipped for flight in known icing. It entered icing conditions about half an hour into the flight, shortly after reaching the cruise altitude of about 18,000 ft.

“Flight through icing conditions for an extended period resulted in significant accumulation of ice on the airframe,” ATSB Director Transport Safety Stuart Macleod said.

The pilot continued to operate in icing conditions for an extended period of time before exiting those conditions and descending to 16,000 ft. Subsequently, the pilot deactivated the propeller de-ice and engine ice-protection systems, which in turn led to a flameout from ice ingestion.

“Attempts to restart the engine were unsuccessful, most probably because of a phenomenon known as rotor lock – where rapid and differential cooling of the engine’s components temporarily prevents it from rotating,” Mr Macleod explained.

Without engine power, the pilot conducted a glide approach towards Moruya Airport on the New South Wales South Coast.

“While the pilot was able to get near the airport, the subsequent manoeuvring compromised the ability to remain visual with the airport and assess the glide approach, resulting in the aircraft being too low to reach the most appropriate runway,” Mr Macleod said.

“Subsequent distraction led to a misjudged approach to the remaining runway options.”

The aircraft impacted terrain about 560 m north of the runway threshold and was destroyed. The pilot was seriously injured, and the passenger sustained minor injuries.

“This investigation highlights that thorough knowledge of an aircraft’s limitations and systems, in combination with an understanding of hazardous weather and aviation meteorological products, is critical to safe and effective flight operations,” said Mr Macleod.

“Icing conditions can be extremely hazardous to aircraft. Every icing encounter, to some extent, is unique and unpredictable.”

Mr Macleod stressed that pilots should carefully evaluate all available relevant meteorological information when determining whether icing conditions are likely along the planned flight path.

“Where the aircraft is not certified or equipped to operate in icing conditions, any ice-protection systems on the airframe, propeller, or engine should be regarded as a means to provide time to exit unexpected icing conditions, not to continue to operate in those conditions.”

In addition, the ATSB investigation emphasises that practice and proficiency in simulated forced landings and power-off approaches can improve the likelihood of successfully managing emergency situations.

“Although forced landings can occur in a variety of circumstances, in general, pilots should focus on remaining visual with the intended landing area in order to accurately assess the aircraft’s performance in glide and reach key decision points to refine the course of action,” Mr Macleod said.

The investigation also identified a number of other factors associated with pre‑flight preparation and the operation of the aircraft and its systems.

Finally, the ATSB also found that the seatbelts and shoulder harnesses worn by the pilot and passenger probably reduced the extent of their injuries, and the prompt attendance of nearby paramedics further reduced their risk.

Read the final report: Engine failure and collision with terrain involving Cessna P210N, N210BA, near Moruya Airport, New South Wales, on 19 December 2019

A rail maintenance contractor has amended its processes for on-tracking road-rail vehicles after two RRVs travelled about three kilometres without track protection, an Australian Transport Safety Bureau investigation report notes.

On 10 June 2021, two RRVs operated by SPENO Rail Maintenance Australia on-tracked at the Binney Road level crossing at Crystal Brook, South Australia, to undertake ultrasonic rail flaw detection.

Prior to on-tracking, the RRV crew’s track worker level 2 – responsible for track protection – had contacted the network controller and requested protection limits from Signal 24 Crystal Brook.

While Binney Road level crossing is in the town of Crystal Brook, the signal the track worker was intending to reference was actually Signal 24 Rocky River on the track operator’s network plan. Signal 24 Crystal Brook is about 3 kilometres further down the line.

After clarifying with the track worker that the RRVs intended to travel down the Westbound Mainline, the network controller applied blocking facilities at Signal 24D Crystal Brook.

“This request and confirmation for protection limits from Signal 24D Crystal Brook instead of Signal 24 Rocky River meant the two RRVs on-tracked in an area without protection from other rail traffic,” ATSB Director Transport Safety Dr Stuart Godley said.

“They subsequently travelled for about three kilometres before reaching a set of points prior to the section of track where protection had been applied.”

The network controller recognised the safeworking breach when the RRV’s track worker requested the points be set for the Westbound Mainline so they could enter the intended route to continue ultrasonic testing.

“When the protection was arranged, there was no confirmation between the track worker and the network controller of specifically where the RRVs were going to be put on-track,” Dr Godley explained.

This incident highlights the importance of identifying the location that travel or work on track will commence.

“Competent workers should provide all the information required for network controllers to identify and confirm that protection limits adequately cover the intended work site,” Dr Godley said.

“Confirmation of location is especially important for providing blocking protection for RRV movements.”

Read the final report: Safeworking Breach of Road-Rail Vehicles, Crystal Brook, South Australia, on 10 June 2021

A collision between a bulk carrier and a fishing vessel off Port Adelaide highlights the importance of navigation watchkeepers on vessels utilising all available means to maintain a proper lookout, an Australian Transport Safety Bureau investigation stresses.

Just after 0430 on the morning of 29 February 2020, the fishing vessel Sandgroper collided with the 108-metre self-discharging bulk carrier Accolade II, just off the entrance to Port Adelaide, in darkness and clear visibility conditions.

Sandgroper sustained significant structural damage to its starboard bow, while Accolade II sustained only minor damage to its deck structures and railings on the ship’s starboard side. In addition, Sandgroper’s anchor was found lodged in Accolade II’s deck railings.

There were no reported injuries on either vessel.

“In the time leading up to the collision a proper lookout using all available means was not being maintained on board either vessel,” ATSB Director Transport Safety Stuart Macleod said.

“Consequently, neither was aware of the risk of the collision posed by the other, until shortly before the collision, when it was too late to take effective avoiding action.”

Mr Macleod noted the navigation bridge team onboard Accolade II did not have a complete appreciation of the traffic situation, and of the risk of collision outside the port channel, before they exited the channel prior to the collision.

“In particular, effective use was not made of the ship’s radar and a dedicated lookout was not posted in darkness,” he said.

“And while Sandgroper’s skipper did initially sight Accolade II while it was still in the channel, a proper lookout was not subsequently maintained using all available means, including radar and monitoring the port’s working channel on the radio.”

As a result, Sandgroper’s skipper was not aware that Accolade II had exited the channel, and that a close quarters situation was developing.

“Collisions between trading ships and small vessels continue to occur around the Australian coast, and the safety of fishers and people in small boats continues to be of real concern to the ATSB,” Mr Macleod said.

“ATSB investigations have consistently shown that keeping a proper lookout by all available means – including radar, radio, and automatic identification system (AIS) transceiver – in accordance with the collision regulations, could have prevented most of these collisions.”

While Sandgroper was not required to be fitted with an AIS transceiver, it would have improved the vessel’s detectability.

“An AIS would have increased the chances of the fishing vessel being detected by Accolade II’s bridge team in sufficient time to avoid collision.”

Sandgroper has subsequently been fitted with an AIS, while the managers of Accolade II have advised the ATSB that a navigational audit of the ship’s operations has since been conducted, resulting in several recommendations to improve the ship’s bridge resource management practices.

Read the final report: Collision between Accolade II and Sandgroper, off Port Adelaide, South Australia, on 29 February 2020

Key points

• A pilot attempted to take-off from a closed runway at Gunnedah after failing to check the local NOTAM in pre-flight planning; 
• At the time of the incident no works safety officer was on-site, and there was no ground-based closed runway signage in place; 
• Airport operator was not aware of recent updates to Manual of Standards for Aerodromes, as email address registered with CASA was not being monitored. 

A twin-turboprop aircraft sustained substantial damage when attempting to take-off from a runway that had been closed for repair works, an Australian Transport Safety Bureau investigation details. 

The Fairchild Industries SA226-T Merlin had landed at Gunnedah, northern NSW on the afternoon of 19 August 2020, and was parked there overnight.  

The following morning, in line with a NOTAM published the previous day closing the runway from 0700 to enable runway repair works, a work crew had excavated two holes from the runway pavement (measuring 3 m wide by 5 m long and about 30 cm deep). 

That afternoon, at about 1230 while the work crew was off-site from the airport during their lunchbreak, the Fairchild pilot commenced a take-off run on the runway for a flight to the Gold Coast. 

As the aircraft accelerated, the pilot saw the two rectangular holes excavated from the runway pavement. The pilot attempted to avoid the holes, but they were struck by the aircraft’s left main landing gear. 

“The aircraft sustained damage to its left main landing gear assembly, which resulted in it collapsing, and the left propellor striking the ground,” ATSB Director Transport Safety Dr Stuart Godley explained.  

“The aircraft veered off the runway and came to rest outside the flight strip.” 

The pilot – the sole occupant on board the aircraft – was uninjured. 

“The ATSB investigation found that during pre-flight planning, the pilot had not checked for relevant NOTAMs, including one stating that Gunnedah Airport was closed due to works in progress,” Dr Godley said. 

NOTAMs are accessible via the National Aeronautical Information Processing System (NAIPS) web portal and contain information concerning the establishment, condition, or change in any aeronautical facility, service, procedure, or hazard. 

“An essential component of pre-flight planning is to check all NOTAMs relevant to the planned flight,” Dr Godley said.  

The investigation also found that while the work crew was away on their lunch break there was no works safety officer on site. Further, while a white cross had been placed at the main windsock, visible to aircraft arriving overhead, there were no ground-visible unserviceability markings on the runway.  

Both measures are required by the Civil Aviation Safety Regulations Part 139 Manual of Standards (MOS) for Aerodromes. 

“Aerodrome works staff were not aware of updated MOS requirements that had come into effect seven days earlier, and had interpreted the superseded MOS to not require unserviceability markings if the whole aerodrome was closed,” Dr Godley said. 

The Gunnedah Airport operator had not received notification of the updated MOS because the email included on CASA’s mailing list was for a member of staff who had left the operator. No autoreply, forwarding, or ‘hard bounce’ was in place on the email address, so CASA was not aware the email had not been received. 

“To ensure receipt of correspondence that may affect safety of aircraft operations, aerodrome operators should ensure CASA is provided up to date contact details, particularly following changes to staff,” Dr Godley concluded. 

Read the final report: Take-off from a closed runway involving Fairchild Industries SA226, VH-LDQ, at Gunnedah Airport, New South Wales, on 20 August 2020

A Beechcraft Baron descended below minimum safe altitude during a night visual approach to Parafield Airport when the pilot lost situational awareness, an Australian Transport Safety Bureau investigation has found.

The Baron was conducting a charter flight under instrument flight rules (IFR) from Ceduna, on the west coast of South Australia’s Eyre Peninsula, to Parafield, in Adelaide’s north, on the evening of 13 May 2021. The pilot and a single passenger were on board.

During the flight, the pilot observed the aircraft’s tracking was ‘snaking left to right’ when the autopilot was engaged. The autopilot also did not turn the aircraft as rapidly as the pilot expected on a left turn towards Parafield.

Shortly after the pilot completed that turn manually and re-engaged the autopilot, Parafield air traffic control cleared the Baron for a night visual approach, and the aircraft descended towards the airport.

“At this time, the pilot’s focus was on the autopilot, resulting in the pilot losing sight of the runway and inadvertedly overflying the airport, towards an area of rising terrain at an altitude well below the minimum safe altitude,” ATSB Director Transport Safety Stuart Macleod explained.

“The pilot maintained this low altitude and continued the approach while looking for the runway.”

Despite being at night, there was enough light for the Parafield tower controller to see the aircraft and the hill-line to the east, so its terrain clearance did not raise concerns.

After losing sight of the runway, the pilot maintained a stable aircraft attitude and altitude as they could see the artificial street lighting on the ground, and had good visibility ahead and below the aircraft. They were also generally familiar with Parafield Airport.

However, the pilot had lost sight of the airport at night when the ability to visually identify obstacles was limited, so the safest option was to initiate a go-around and climb to the minimum safe altitude.

The aircraft was outside the airport’s circling and control area for about a minute, before the pilot was able to re-enter the control area under air traffic control guidance, and join the upwind leg of the circuit. The aircraft subsequently landed safely. No defect with the aircraft’s autopilot system was identified after the flight.

The ATSB’s investigation into the incident found that the pilot lost situational awareness, probably as a result of distraction due to the perceived autopilot issue.

“This incident highlights that unless there is a problem affecting flight safety, pilots should remain focused on monitoring aircraft and approach parameters, which provides assurance that an approach can be safely completed,” Mr Macleod said.

“If a visual approach cannot be completed pilots must inform air traffic control so assistance can be provided.

“If the criteria for the safe continuation of an approach are not met – for example losing sight of the runway – pilots must initiate a go-around and maintain a safe altitude to reduce the risk of colliding with obstacles or terrain.”

Since this incident, the aircraft’s operator, Hartwig Air, has updated its training program to include a threat and error management course.

Additionally, Airservices Australia has advised that it will brief its Parafield Airport tower controllers on the incident, including information on the circling area, descent below the minimum safe altitude during visual approaches, go-arounds, and the ‘safety alert’ procedure.

This procedure is intended to warn pilots that their aircraft is in unsafe proximity to terrain, obstruction, active restricted/prohibited areas, or other aircraft.

Read the final report: Flight below the minimum safe altitude involving Beechcraft Baron 95-B55, VH-CBG, 5 km north-east of Parafield Airport, South Australia, on 13 May 2021

Key points

• A King Air departing Essendon for Albury yawed to the left during take-off roll;
• ATSB found that the left engine power lever had migrated rearwards as the friction lock had not been sufficiently adjusted during the pre-flight checks;
• King Air power lever friction locks require careful adjustment to prevent power lever migration, particularly during take-off.

The insufficient tightening of a friction lock during pre-flight checks resulted in a Beechcraft King Air’s left power lever migrating to idle during the take-off roll, an ATSB investigation report details.

The King Air B200C aircraft, operated by Pel-Air, was departing Essendon for Albury on the night of 19 August 2021 to conduct a medical retrieval flight with a pilot, paramedic and doctor on-board. During the take-off, the aircraft experienced a reduction in power on the left engine and an uncommanded yaw to the left.

The pilot, who had about 16,000 hours of aeronautical experience, of which 42 hours were on the King Air B200C, initially managed the situation as an engine power loss and focused on maintaining directional control. However, when troubleshooting, they identified that the left engine power lever had migrated rearwards to the idle position. In response, the pilot moved the power lever back to take‑off power and adjusted the friction lock to prevent further movement.

The flight continued to Albury without further incident.

“The King Air’s power lever friction locks require careful adjustment to prevent the power levers moving inadvertently, particularly during take-off,” said ATSB Director Transport Safety Dr Stuart Godley.

“This is a characteristic generally known among King Air operators and pilots.”

When interviewed by the ATSB, the incident pilot reported that they were new to the B200C and unaware that power lever migration could occur during take‑off.

Another pilot from the operator noted that, until a pilot experienced a power lever migration, it could be difficult to know how much to tighten the friction locks.

“The power lever friction locks fitted to the King Air require careful adjustment to prevent power lever migration during take-off,” said Dr Godley.

“Operators should ensure pre-flight checks provide opportunities to confirm friction lock settings before the take-off run, and ensure pilots have adequate knowledge of friction lock sensitivity to help prevent and recover from inadvertent power lever migration.”

Dr Godley said the ATSB has released a safety advisory notice to all operators and pilots of King Air aircraft advising of power lever migration and the need to be aware of the careful adjustment required for the power lever friction lock.

“This incident highlights the importance of having a detailed understanding of the characteristics that may be specific to an aircraft type,” he said.

“In the case of the King Air, the design of the power lever system means that the friction locks required careful adjustment to prevent power lever migration.”

Read the final report: Uncommanded power reduction involving Beechcraft King Air B200C, VH-VAH, at Essendon Fields Airport, Victoria, on 19 August 2021

Helicopter operators and flight crew involved in rescue hoist operations should review their operational practices to ensure hoist operation and hook stowage are in accordance with the manufacturers’ published procedures, the Australian Transport Safety Bureau (ATSB) urges.

The advice comes as the ATSB publishes its final report into a rescue hoist cable failure which occurred when a New South Wales National Parks and Wildlife Service-operated AS350 B3 Squirrel helicopter was conducting personnel and equipment winching near Bulga, NSW on 5 February 2020. A crewman operating the helicopter’s Breeze Eastern-manufactured winch detected the outer strands of the load cable toward its termination into the hook assembly had loosened in respect of the inner core.

During a subsequent ‘cable conditioning’ hoist operation intended to tension the cable and realign the wires to restore the cable integrity, the cable fractured at the hook assembly while under load, releasing a 160 kg weighted bag and the hook assembly to the ground. There was no damage to the helicopter or injuries to personnel.

The ATSB’s investigation found that variations in the operator’s hook stowage practices over an extended period of winching operations led to inadequate compression of the hook assembly and subsequent wear of the load cable. The wear damage was due to vibration and movement of the hook assembly during periods of helicopter operation. This led to a significant reduction in the cross-sectional area of the cable, fatigue and fracture of the strands and an associated reduction in cable strength.

It is likely that specific post-flight inspection requirements for the Breeze Eastern rescue hoist required in a Civil Aviation Safety Authority’s Airworthiness Directive were not being adequately completed by the operator, the investigation found. The inspections were targeted at minimising wear damage to the load cable by ensuring correct stowage of the hook assembly at the end of each flight.

The ATSB also found that the operator’s method of cycle counting during operation of the rescue hoist led to an accumulation of cycles that significantly exceeded the helicopter manufacturer’s recommended life-limit. That exceedance probably compounded the level of wear damage sustained by the load cable.

“The ATSB recommends that pre- and post-flight inspection requirements of the hook and cable assembly, along with any recurring scheduled maintenance of the hoist system, are closely reviewed to ensure that they are completed in accordance with the manufacturers’ instructions,” Director Transport Safety Stuart Macleod said. “Improper stowage of the hoist hook assembly can lead to excessive movement and accelerated wear of the cable, which, if undetected, could have a fatal outcome.”

Mr Macleod reiterated that should a load cable exhibit an increased frequency of outer strand loosening requiring a condition operation, operators should be particularly mindful to check for narrowing or ‘necking’ of the cable at the ball end within the swivel hook assembly.

“Narrowing or necking of the cable can signify that the cable has become damaged due to extreme wear and may no longer be safe to use,” he said.

The ATSB first highlighted this critical safety messaging in April 2020, approximately two months after the incident, when it published a Safety Advisory Notice (AO-2020-013-SAN-001) addressed to helicopter operators and flight crew involved in rescue hoist operations.

Read the final report: Rescue hoist cable failure involving AS 350 B3, VH-UAH, 1 km south-west of Bulga, New South Wales, on 5 February 2020

Key points

• Engine of Dynaero MCR-01 VLA ran rough just after take-off and pilot commenced a turn to the left before stalling and impacting terrain;
• ATSB found multiple tasks in the aircraft’s return to service after a significant period of inactivity were not adequately carried out;
• Pilots are cautioned against attempting to turn back to the runway in a partial power loss situation.

A Dynaero aircraft’s partial power loss soon after take-off from Serpentine Airfield, WA created a demanding, time-critical situation prior to a fatal collision with terrain, an ATSB investigation report outlines.

On the afternoon of 28 December 2020, the single-engine Dynaero MCR-01 light aircraft took off from Serpentine Airfield, south of Perth, to conduct a post-maintenance check flight.

About 300 ft above ground level, the aircraft’s engine began to run rough, but continued to operate. The pilot commenced a turn to the left, and the aircraft appeared to decelerate in a nose-high attitude without gaining height.

Shortly after, the aircraft was observed to aerodynamically stall, pitch nose-down, and impact terrain. The pilot, who was the sole occupant, was fatally injured, and the aircraft was destroyed.

The ATSB investigation’s final report notes this accident is another reminder of the challenges pilots face in the event of a partial power loss after take-off, as detailed in the ATSB’s Avoidable Accidents handbook.

“Partial engine power loss is a more frequent, and a more complex occurrence than complete engine power loss,” ATSB Director Transport Safety Dr Stuart Godley said.

“The ATSB encourages pilots to review the recommended partial power loss procedure in their aircraft’s pilot operating handbook, and cautions against attempting to turn back towards the runway under reduced power unless in controlled situations where sufficient altitude exists."

The ATSB found multiple maintenance tasks in the aircraft’s return to service after a significant period of inactivity were not adequately carried out, and that the left carburettor of the aircraft’s engine was missing a component, and contained a significant amount of contamination.

“This likely resulted in over-fuelling of the carburettor at a low power setting, and likely produced subsequent engine rough running at higher power settings,” Dr Godley explained.

Additionally, the ATSB found the pilot was unfamiliar with the aircraft and engine type, which increased the risk of not being able to adequately manage an inflight emergency.

The ATSB also found the pilot had probably consumed a significant amount of alcohol the night before the accident, which increased the risk of post-alcohol impairment.

“Blood-alcohol can persist the day after significant alcohol consumption, and the residual effects of alcohol may impair performance, especially in demanding and time critical situations,” Dr Godley concluded.

Read the final report: Partial power loss and collision with terrain involving Dynaero MCR-01 VLA, VH-SIP, near Serpentine Airfield, Western Australia, on 28 December 2020

Key points

• A VLocity passenger train collided with closed level crossing gates beyond Ballarat Station after failing to stop;
• The investigation found that the train’s sanding system was ineffective at improving wheel-rail adhesion, and that safety controls were ineffective in mitigating against a train arriving at Ballarat Station travelling at excessive speed;
• The occurrence highlights the importance of risk controls to prevent collisions because of slippery rail conditions.

A Vlocity passenger train’s sanding system was ineffective in improving wheel-rail adhesion as the train approached Ballarat Station on the evening of 30 May 2020 after light rain and in windy conditions, a transport safety investigation details.

The three-car V/Line Vlocity train was operating a service from Melbourne to Ballarat and Wendouree when, unable to stop at Ballarat Station, the train collided with the Lydiard Street North level crossing gates, which were closed to rail traffic, according to the investigation by Victoria’s Chief Investigator, Transport Safety (who conducts rail investigation in Victoria on behalf of the Australian Transport Safety Bureau).

“Slippery rail conditions existed for at least the final 2.5 km of the approach to Ballarat Railway Station and probably the final 5 km,” said Chief Investigator, Transport Safety Mark Smallwood.

“Light rain was the primary environmental factor in the development of the slippery conditions, and the very low levels of adhesion at the contact between the train’s wheels and the rail head substantially reduced the train’s braking performance.”

The driver made initial brake applications approximately 5.1 km from Ballarat Station when the train was travelling at just over 160 km/h, and made a full service brake application about 2.6 km from the intended stopping point. However, the train did not decelerate sufficiently and could not be stopped, the report details.

The train passed through the station and collided with the level crossing gates at an estimated speed of between 93 and 97 km/h. After impacting the gates, the driver subsequently brought the train to a stand approximately 640 m beyond the station.

One of the two passengers on board required hospitalisation, and the train driver and conductor sustained minor injuries. The impact destroyed the pair of southern gates, damaged the front and side of the train, and resulted in gate debris being scattered into the surrounding area.

“The investigation found that the train’s sanding system, which is intended to improve adhesion in slippery conditions by applying sand to the rail head, was ineffective at improving braking performance,” said Mr Smallwood.

Reviewing the train’s data logger, investigators established that the train’s wheel slip/side protection (WSP) and sanding systems both automatically activated during the approach to Ballarat Station.

“Several factors potentially adversely influenced the performance of the sanders that evening, including their design configuration, vegetation contamination in one sander box, and the lack of sand in a second,” said Mr Smallwood.

“There were missed opportunities to identify weaknesses in the sander configuration, while maintenance of the sander units did not test for discharge flow rates, and train preparation processes did not ensure a required minimum amount of sand in the sand boxes.”

Mr Smallwood noted that since the incident V/Line has implemented a number of measures to improve sander performance, and has installed sanders on the intermediate cars of three-car VLocity diesel multiple unit sets.

The investigation also found that safety controls were ineffective in mitigating against a train arriving at Ballarat Railway Station travelling at excessive speed and being unable to stop before colliding with the crossing gates.

To enhance management of this risk, V/Line has introduced a number of interim measures including reducing the permitted train speed on the approaches to Ballarat Station from 160 to 80 km/h, and installing overspeed-triggered operation of the Lydiard Street North level crossing protection.

“This occurrence has highlighted the importance of rail operators having risk controls in place to prevent collisions because of slippery rail conditions,” Mr Smallwood said.

“Controls include effective train-borne equipment such as wheel slip/slide protection systems and sanders, and targeted risk controls at locations vulnerable to risks associated with train overrun.”

Read the final report: Collision of passenger train 8185 with level crossing gates, Lydiard Street North, Ballarat, Victoria, on 30 May 2020