The ATSB is reminding freight operators of the need to ensure train drivers receive regular training and competency assessments on how to operate on steep continuous gradient rail routes.

On 22 April 2017, a Qube Logistics grain train was travelling from Bogan Gate to Port Kembla, NSW. During its descent down Illawarra Mountain—one of the steepest descents in the NSW rail network— the driver realised control was lost and advised network control that the train was running away..

The ARTC network controller with the Sydney Train’s controller ensured the train had the ‘full road’ with no rail traffic in its path. Reaching a maximum speed of 107km/h as it rounded a curve approaching Unanderra Station, the train came to a stop once it reached the rising gradient at the Unanderra North Junction.

The ATSB found the methods used to control the train during the descent were not in line with the train handling procedures.

Ten brake applications were made as the train descended the mountain between Dombarton and Unanderra. However, the use of multiple brake applications to try and control the train meant the pneumatic braking system was unable to fully recharge between applications reducing its braking capability. Control over the train was further reduced when its dynamic braking system was rendered inoperative.

The ATSB also found actual mass of the train was 10 per cent heavier than recorded. It is likely that the additional weight placed an extra load on the braking system and affected the handling characteristics of the train.

The incident highlights the need for freight operators to ensure regular training and competency checks of train crews who operate on steep descents. Contingency plans and procedures for the management of runways in this area should be continually reviewed and tested by rail infrastructure managers.

Read the final report: Runaway of grain train 8960, Dombarton to Unanderra, New South Wales, on 22 April 2017

The ATSB’s investigation into the fatal accident of an Air Tractor AT-502 revealed several factors that contributed to the tragedy, and the measures that aerial application pilots and operators need to be taking.

The accident occurred on 5 November 2016 at an airstrip at Cryon, NSW. The aircraft was conducting aerial application operations. After commencing the take-off, the aircraft failed to gain any significant altitude, and clipped the top of a fence about 1,300 m beyond the start of the runway. After climbing about 20 feet above the ground, the aircraft descended, and collided with trees and the ground before coming to rest inverted. The pilot was fatally injured, and the aircraft was destroyed by impact forces and a fuel-fed fire.

The ATSB investigation found that the flaps were either never extended or were retracted at some point during the take-off. The reason for the retraction could not be determined, but it significantly degraded the take-off and climb performance. This effect was compounded by the estimated weight of the aircraft, the local temperature and the wind conditions.

The aircraft reached a height above the ground where the reduced benefit of ground effect further degraded the aircraft’s performance. The low height and airspeed precluded the pilot from turning the aircraft towards a clear area, and so the aircraft descended into the trees.

... the aircraft manufacturer is updating the maintenance section of the aircraft owner’s manual to specify that the gatebox and emergency dump controls are to be inspected periodically for condition, function and adjustment.

Recorded data from the aircraft indicated that the pilot had attempted to dump the hopper contents after becoming airborne – a move which would have achieved significant gains in climb performance. However, for unknown reasons, a complete dump was not achieved.

The performance benefits of quickly and significantly reducing an aircraft’s weight means that a proper functioning emergency jettison system to dump the contents of a hopper is vital. Pilots rely on the system in case performance is inadequate, particularly when taking off with a heavy load. Registered operators should ensure adequate ongoing maintenance and regular checks to maintain serviceability of the system.

As a result of the accident, the aircraft manufacturer is updating the maintenance section of the aircraft owner’s manual to specify that the gatebox and emergency dump controls are to be inspected periodically for condition, function and adjustment.

This accident also serves as an important reminder for pilots to monitor weather conditions like temperature and wind and to anticipate the potential adverse effects of local conditions on aircraft performance.

Read the final report: Collision with terrain involving Air Tractor AT-502, VH-LIK, 50 km east of Walgett Airport, New South Wales, on 5 November 2016

The release of the ATSB’s report into the terrain awareness warning system alert involving Eurocopter BK-117C-2, VH-SYB,  is reminder for pilots of the limitations of night vision imaging systems (NVIS) and night vision goggles (NVGs).

On 26 October, the helicopter took off under night visual flight rules (NVFR) from the Crookwell Medical Helicopter Landing Site with the pilot and aircrew member both wearing NVGs. Shortly after take-off, the helicopter entered unexpected low cloud and the pilot initiated the procedure for an inadvertent entry into instrument meteorological conditions.

As the helicopter’s climb reduced, the pilot lowered the helicopter’s nose to regain airspeed but inadvertently over corrected the pitch angle, triggering a terrain caution alert.  

The ATSB found the pilot was likely distracted, during a period of high workload, by the reflection of the helicopter’s anti-collision light against cloud, which was compounded by the use of NVGs.

Clearer guidance may have led to the conduct of a less risker IFR operation

NVGs can increase a pilot’s ability to see the horizon, terrain and objects, but it is important to remember there are also risks and limitations associated with their use. Ambient light, reflections and even the position of the moon, can reduce their effectiveness. NVG use needs to be supported by clear and robust processes from the operator.

During the investigation, the ATSB found there were also some ambiguities in the operator’s manuals about when to conduct NVFR operations with NVIS versus the use of instrument flight rules. Clearer guidance may have led to the conduct of a less risker instrument flight rules operation.

Information on the proper implementation and use of NVIS with NVGs and their benefits and limitations is available in the ATSB aviation research report Night Vision Goggles in Civil Helicopter Operations.

Read the final report: Terrain awareness warning system alert involving Eurocopter BK 117C-2, VH-SYB, near Crookwell, New South Wales, on 21 October 2016

The ATSB is highlighting the importance of the early detection and treatment of defects of rail infrastructure, especially those that could cause a rail facture and lead to derailment.

The ATSB’s investigation into the derailment of freight train 1501S, near Dry Creek in South Australia on 28 July 2017, found a vertical split head defect had developed through the centre line of the lower leg rail in the curve approaching Dry Creek South.

The ATSB determined the defect had developed undetected from impurities in the rail during its manufacture. When a preceding train travelled over the defect, it caused a break in the rail that was not obvious – visually – to the crew of the following train 1501S. When 1501S travelled over the break, a 2-metre section of rail fragmented derailing its last three wagons.

Acting ATSB Executive Director Transport Safety, Patrick Hornby said the defect in the rail failed to be detected, despite the previous month’s ultrasonic track inspection.

No follow-up action was triggered by the testing provider as required by the track owner creating a missed opportunity for the detection and possible treatment of a defect

“ATSB investigators found that ultrasonic testing indicated the presence of an anomaly, however these results were attributed to the rail’s poor surface condition and not a potential rail defect,” Mr Hornby said.

“No follow-up action was triggered by the testing provider as required by the track owner, creating a missed opportunity for the detection and possible treatment of the defect.”  

Following the incident, the testing provider reviewed its operational and reporting procedures and the rail owner confirmed the effectiveness of its code of practice for ultrasonic rail testing.

“This incident highlights the importance of maintenance providers reporting testing anomalies, to highlight operational risk and to initiate further action,” Mr Hornby said.

Read the final report: Derailment of freight train 1501S, near Dry Creek, South Australia, on 28 July 2017

The ATSB recommends hot-air balloon operators, following their pre-flight safety briefing, have passengers demonstrate the landing position in the basket, to ensure there is no confusion about what to do in an emergency.

On 8 February 2018, a Kavanagh B-350 hot-air balloon, registration VH-EUA, operated as a scenic charter flight north of the Yarra Valley in Victoria with one pilot and 15 passengers on board.

About 45 minutes into the flight, the balloon encountered a sudden wind change with associated turbulence. The turbulence initially caused the balloon to increase altitude but then it began to descend. The pilot decided to conduct an emergency landing in a nearby paddock. Eleven passengers were injured in the resulting hard landing, with four requiring hospitalisation.

Acting ATSB Executive Director Transport Safety, Mr Patrick Hornby said that despite a pre-flight safety briefing, there was confusion among the passengers about what to do when the pilot advised them to get into their landing position.

It is good practice to ensure that all passengers know what they need to do after they have boarded the basket, including what they need to do in an emergency situation.

“The accident happened when the balloon encountered an unexpected wind change,” Mr Hornby said. An emergency landing was conducted, and some of the passengers were confused about what to do.”

The use and availability of Illustrated safety information cards is also recommended, particularly for passengers from a non-English speaking background. These should be kept or displayed in a convenient location for passengers to access or refer to.

“There are some important safety lessons from this accident,” Mr Hornby said. “It is good practice to ensure that all passengers know what they need to do after they have boarded the basket, including what they need to do in an emergency situation. Passengers need reminders.”

On 10 October 2018, the Civil Aviation Safety Authority released a cabin safety bulletin (Cabin safety bulletin 12 - General aviation passenger briefings(Opens in a new tab/window)) to provide guidance on how to conduct an effective safety briefing to improve passenger situational awareness and their response during an emergency.

Read the final report: Hard landing involving Kavanagh B-350 hot-air balloon, VH-EUA, 6 km east-north-east of Yarra Glen, Victoria, on 8 February 2018

The ATSB is urging flight crews to stop and seek further guidance when confronted with any ambiguous situations pre-flight.

The ATSB’s investigation into an incident involving a passenger flight brings an important warning for crews about the potential for anomalies in warning systems.

The incident occurred on 26 May 2018, when a SAAB 340B was taxiing at Esperance Airport, Western Australia. The aircraft was scheduled to conduct a passenger flight to Perth with three crewmembers and 32 passengers on board.

As the aircraft taxied, the first officer (FO) conducted a test of the ice protection system, and the flight crew received a Master Caution. The warnings did not match any of the scenarios in the Quick Reference Handbook (QRH) checklist. The Captain discussed the warnings with the FO, how had not detected any defects in the de-icing system during the daily walk-around check of the aircraft.

The flight crew concluded that the warnings were most likely the result of a faulty sensor and there was no risk to the safety of the flight. They noted that the forecast freezing level was 7,500 ft and if necessary, the flight to Perth could be conducted as low as 4,000 ft. They elected to proceed with the flight as scheduled and the flight was conducted without further incident.

… if confronted with an abnormal or ambiguous situation pre-flight, which have the potential to affect safety of flight, crews should stop and seek further guidance.

After landing, the flight crew found a tear in the right stabiliser boot.

The ATSB investigation found that the crew had likely conducted the flight with a small defect in the boot, which increased in size during the flight. The reason for the ambiguous nature of the warnings could not be determined.

The incident highlights an important warning for flight crews regarding the potential for anomalies to occur in the operation of warning systems. In the event that fault indications are ambiguous and there is the possibility of affecting the safety of the flight, it is important to take the necessary, conservative precautions to resolve the issue prior to conducting the flight.

Damaged de-icing boot

Read the final report: De-icing boot failure involving Saab 340, VH-ZLH, Esperance Airport, Western Australia, on 26 May 2018

The Australian Transport Safety Bureau’s (ATSB) investigation into the in-flight propeller loss involving a Saab 340B was the result of a fracture of the propeller shaft on the right engine propeller gearbox (PGB).

The right propeller separated from the aircraft, with 16 passengers and three crew on board, while it was on approach to Sydney Airport from the south-west on 17 March 2017.

The ATSB found the fracture was due to a fatigue crack that originated in a propeller shaft flange dowel hole and spread through the shaft until it could no longer transmit the loads required to maintain the propeller on the aircraft.

The NSW Police Aviation Support Branch undertook a search operation for the propeller four days later. The propeller was located in dense bushland at Revesby, and airlifted out.

ATSB Chief Commissioner Greg Hood said the investigation was unable to determine, conclusively, what caused the fatigue crack to occur.    

“This was an extremely rare event, and the crew should be commended.”

“The ATSB’s investigation found the crew demonstrated a high level of professionalism in their communication, coordination and application of the safety checklist procedures in their response to the incident, which resulted in an uneventful single-engine landing at the airport,” Mr Hood said.

“This was an extremely rare event, and the crew should be commended.”

Following the incident, the engine manufacturer, General Electric, and the airline, undertook a number of proactive safety actions.

“The airline and the engine’s manufacturer have undertaken a number of proactive safety actions, such as the release of new service bulletins and airworthiness directives, and changes to their maintenance regime, to reduce the risk of this extremely rare event from occurring again,” Mr Hood said.

“Flying remains as one of the safest forms of travel for the public. Here in Australia, we have one of the best aviation safety records in the world.”

Read the final report: In-flight loss of propeller involving Saab 340B, VH-NRX, 19 km (10 NM) south-west of Sydney Airport, New South Wales, on 17 March 2017

The Australian Transport Safety Bureau’s (ATSB) final report into the loss of control and collision with terrain involving Beechcraft B200 King Air, registered VH-ZCR, highlights the importance of following a cockpit checklist.

During take-off from Essendon Airport, Victoria, on the morning of 21 February 2017, the aircraft diverged to the left of the runway centreline.

Having reached a maximum altitude of 160 feet (49 metres) above ground level, the aircraft began to descend with an increasing left sideslip. The aircraft subsequently collided with the roof of a building in the Bulla Road Precinct Retail Outlet Centre of Essendon Airport.

The aircraft was destroyed by the impact. The pilot and four passengers were fatally injured. Two people on the ground received minor injuries.

The ATSB’s investigation found that the pilot did not detect that the aircraft’s rudder trim was in the full nose-left position prior to take-off. The position of the rudder trim, which assists a pilot with controlling an aircraft’s movement around the vertical axis, resulted in a loss of directional control and had a significant impact on the aircraft’s climb performance.

ATSB Chief Commissioner, Mr Greg Hood said this accident emphasised the importance of having a cockpit checklist in place applicable to an aircraft’s specific and current modification status.

“Checklists are a part of every pilot’s pre-flight risk management plan and are an essential tool for overcoming limitations of the human memory,” Chief Commissioner Hood said.

“Checklists ensure action items are completed in sequence and without omission. In this particular tragic accident there were opportunities in the checklist that existed for the pilot to ensure the rudder trim was set to neutral prior to take-off.”

In addition to the importance of using a checklist, this accident also emphasises the challenges associated with decision-making during critical stages of a flight.

“Pilots need to carefully consider their decision-making, particularly during critical phases of flight, such as take-off,” Chief Commissioner Hood said.

Read the final report: Loss of control and collision with terrain involving B200 King Air, VH-ZCR, at Essendon Airport, Victoria, on 21 February 2017

Video: ATSB investigation highlights the importance of using a checklist

Click the image to link to view YouTube video

The Australian Transport Safety Bureau (ATSB) has made available on its website the complete library of the iconic aviation safety publication – the Aviation Safety Digest.

The 150 editions of the famed ‘crash comic’ span from 1953 to 1991, and include special editions on human factors, agricultural operations, visual flight and wake turbulence – to name just a few.

Speaking at the Civil Aviation Historical Society’s Airways Museum at Essendon Airport to officially launch the online editions, ATSB Chief Commissioner Greg Hood said this remarkable collection now preserves such an important part of Australia’s aviation safety history.

“Produced by our predecessor over 38 years, the Aviation Safety Digest provided valuable information and advice to help promote aviation safety in Australia,” Mr Hood said. “Australia has been at the forefront of transport safety for many years. It is important that we preserve and display our history, and this online library is an important historical record of aviation safety in the country.”

Chief Commissioner Hood personally thanked Ross Robotham, who scanned every page of each issue, and Research Fellow at the Civil Aviation Historical Society, Dr Peter Hobbins, who made the issues searchable.

“Without the diligence of Ross and Peter, it would have been impossible make this valuable aviation safety resource publicly available,” Mr Hood said,

“Making the collection of the Aviation Safety Digest available online is a wonderful example of the collegiate nature of Australian aviation.”

Esma Job, widow of Macarthur Job, who was the first full-time editor of the digest, said she was thrilled to see her late husband's work preserved online for everyone to see, now and in the future. 'Mac', as he was known, authored 64 issues of the digest over 14 years.

The online library of the Aviation Safety Digest is available on the ATSB website..

Read about the history of the Aviation Safety Digest on the Civil Aviation Historical Society and Airways Museum's website: 

The ATSB is advising pilots to be conservative when relying on pilot reports for runway surface conditions, in particular, when the conditions are considered damp.

The ATSB’s investigation into the reduced braking effectiveness during landing of a Boeing 737 at Christchurch International Airport, 11 May 2015, highlights the how misperceptions of runway surface conditions can lead to runway excursions.

After touch down on runway 29, the Boeing 737 did not decelerate as expected during the later stages of the landing roll. The crew overrode the autobrakes, applied hard manual braking and retained the use of reverse thrust until the end of the runway.

The aircraft stopped about 5 metres from the end of the runway.

The ATSB found that, due to an increased workload, the crew misperceived the runway surface conditions, believing it to have a damp surface condition when in fact it was wet. This resulted in the aircraft’s expected landing performance not being achieved.

Pilots are advised to apply a conservative approach when relying on other pilot reports for runway surface conditions, in particular, when the conditions are considered damp.

ATSB Executive Director, Transport Safety, Mr Nat Nagy said the incident demonstrates how the subjective nature of runway surface reports and braking actions reports can contribute to the risk of a runway excursion.

“There is little standardisation between how pilots, industry and regulators describe runway surface conditions,” Mr Nagy said. “Information provided to pilots is often from multiple sources, with undefined terminology that may only be relevant to a certain time or type of aircraft.

“To overcome this, the International Civil Aviation Organization will be adopting the United States Federal Aviation Administration’s (FAA) runway condition assessment matrix in November 2020.”

The Civil Aviation Safety Authority (CASA) have advised the ATSB they anticipate aligning their runway condition definitions with ICAO post 2020.

“Until then, pilots are advised to apply a conservative approach when relying other pilot reports for runway surface conditions, in particular, when the conditions are considered damp,” Mr Nagy said.

Additionally, the ATSB found, along with the FAA, that the 15 per cent in-flight safety margin applied to actual landing distances may be inadequate under certain runway conditions. CASA has advised they intend to evaluate this finding and update the corresponding advisory material accordingly.

Read the final report: Reduced braking effectiveness during landing involving Boeing 737-800, VH-VOP, Christchurch Airport, New Zealand, on 11 May 2015