The ATSB is urging pilots to ensure they use effective see-and-avoid techniques to avoid traffic conflicts when flying at non-towered aerodromes.

The ATSB’s investigation into a traffic conflict between a Robinson R22 and a Cessna C208 highlights the importance of pilots maintaining a constant visual lookout to avoid traffic conflicts.

On 19 September 2017, a Cessna C208 (VH-SJJ) and a Robinson R22 (VH-MFH) came into traffic conflict at the Ballina Bryon Gateway Airport. The Cessna entered and rolled on runway 06 while the Robinson was on its short final at 200 ft about two thirds along the same runway.

The ATSB found that despite the use of the common traffic advisory frequency (CTAF) and the certified air/ground radio service (CA/GRO) to advise of their positions by both pilots and instructor on board VH-MFH (MFH was on a training circuit) the pilot of VH-SJJ moved onto the runway before he had visually identified the helicopter.

Traffic conflicts are among the most common occurrences at non-towered aerodromes.

ATSB Executive Director, Transport Safety, Mr Nat Nagy says that traffic conflicts are among the most common occurrences at non-towered aerodromes.

“The proper use of the CTAF and the CA/GRO are important tools to build your situational and traffic awareness, but it is also important to maintain a constant visual lookout to confirm the information you are receiving.”

“There are high workloads while flying in and around airports. Things can change quickly, updates on what is happening can take time to reach a pilot, or they can be misheard or not heard at all.

“Maintaining constant visual awareness is a vital technique to ensure you are able to operate safely,” Mr Nagy said. 

Read the final report: Traffic conflict involving Cessna 208, VH-SJJ and Robinson R22, VH-MFH, at Ballina Byron Gateway Airport, New South Wales, on 19 September 2017

Additional reading: A pilot's guide to staying safe in the vicinity of non-controlled aerodromes.

The ATSB is highlighting the need for a shared understanding or ‘shared mental model’ of a ship’s passage plan by bridge crew and harbour pilots to ensure a safe voyage.

The ATSB’s investigation into the near grounding of the bulk carrier Aquadiva in Newcastle Harbour on 12 February 2017 also underlines the importance of a ship’s bridge crew and harbour pilot engaging in effective communication and information exchange to develop this shared understanding or mental model of a ship’s passage plan.

During the investigation, the ATSB found that Aquadiva’s bridge crew had not received the harbour pilot’s passage plan before he boarded. This meant the harbour pilot and the bridge crew were operating with a different set of assumptions for what constituted a safe passage.  

This misunderstanding restricted the ability of the crew to monitor the ship’s progress properly and identify or correct any errors in the ship’s progress.

A shared understanding or mental model of a ship’s passage lets the harbour pilot and bridge crew work together to identify errors and take steps to correct them quickly.

As a result, when insufficient rudder was applied during the ship’s passage through a section of the harbour known as The Horse Show, the bridge crew did not identify the issue or alert the harbour pilot. The ship then slewed, or moved sideways, toward the southern edge of the channel, and went over the limits of the marked navigation channel.

Once the issue was identified, additional tugs were required to arrest the ship’s movement and return it to the channel to complete its safe passage out to sea.

ATSB Executive Director, Transport Safety, Mr Nat Nagy, said a shared understanding or mental model of a ship’s passage lets the harbour pilot and bridge crew work together to identify errors and take steps to correct them quickly.

“This shared understanding can be enhanced through tools such as a portable pilotage unit,” Mr Nagy said.

“In this case it could have helped with the communication between the pilot and bridge crew to point out and clarify the differences between each passage plan.”

Read the final report: Near grounding of Aquadiva, Newcastle Harbour, New South Wales, on 12 February 2017

The ATSB is highlighting the importance of vessels taking early and effective avoiding action and keeping a proper lookout.

The ATSB’s investigation into the collision of a container ship and a fishing vessel reflects an ongoing problem on the Australian coast ­– collisions between small vessels and trading ships.

This serious incident occurred in the Tasman Sea on 23 January 2018, in the very early hours of the morning. The visibility was clear and the seas were calm, with a south-westerly wind up to 10 knots. The container ship Beijing Bridge was en route to Melbourne from Taiwan while the fishing vessel Saxon Onward was northbound for Eden, New South Wales. 

The vessels had been aware of each other’s presence well before the collision took place. About 45 minutes before the collision, Saxon Onward’s watchkeeper had sighted the masthead lights and green sidelight of an approaching ship (Beijing Bridge) on the starboard bow. Meanwhile, the third officer of Beijing Bridge was the officer of the watch and the sole lookout on that vessel’s navigational bridge. He had seen Saxon Onward, along with another fishing vessel, and both vessels were acquired on Beijing Bridge’s radar.

…These are measures that every ship needs to be taking.

As the two vessels closed on each other, they both realised that risk of collision existed and both took action. Beijing Bridge’s course alteration was not substantial, not made in good time, and actually increased the risk of a collision. Saxon Onward made a substantial course alteration, but it was made too late and resulted in the collision. Saxon Onward collided with Beijing Bridge, with the trawler’s port bow impacting the ship’s starboard side. As the trawler scraped down the ship’s side, the skipper stopped the engine and the crew mustered in the wheelhouse.

Beijing Bridge showing surface damage to the hull on the starboard side

Source: Australian Maritime Safety Authority (AMSA)

There were no injuries or pollution reported by either vessel. Saxon Onward suffered substantial damage to its hull but was able to make its way unassisted to the nearby port of Eden. Beijing Bridge resumed its passage and berthed in Melbourne later the same day.

ATSB Chief Commissioner Greg Hood said since 1990, the ATSB have conducted investigations into 39 collisions, with most seeing a recurring type of occurrence.

“Trading ships and small vessels are continuing to collide with each other off the Australian coast,” Mr Hood said.

“Thankfully, this incident did not result in anyone being harmed, but the potential for more serious consequences is concerning.

“Every ship needs to take early and effective action to avoid other vessels and maintain a proper lookout – which is a requirement under international regulations.”

Read the final report: Collision between the container ship Beijing Bridge and fishing vessel Saxon Onward, Tasman Sea, about 3 NM south-east of Gabo Island, Victoria, on 23 January 2018

Further information:
The ATSB has previously published safety bulletins, Safety Bulletin 01 - Ships and Fishing vessels and Safety Bulletin 05 - Fisherman and Safety Awareness at Sea, aimed at highlighting the risks faced by fishing vessels and raising awareness of the common contributory factors present in these collisions.

The ATSB reminds ship operators of the constant danger of ship fires from on board hot work for the removal of sea fastenings.

The ATSB’s final investigation report into a fire on board BBC Xingang, Newcastle, New South Wales, has been released.

On 11 December 2017, hot work (oxy-acetylene welding techniques) were required for the removal of sea fastenings on the ship’s tween deck. Before work started, a safety meeting, between relevant crew and the contracted hot work team, was held to discuss safety measures and procedures.

A fire watch team was arranged and fire blankets were placed in the gaps between the tween deck pontoons to protect the cargo below. However, the hot work created molten metal and other hot material that burnt through to the cargo below and ignited the cargo coverings. The fire was quickly extinguished on discovery.

ATSB Executive Director, Transport Safety, Mr Nat Nagy said ship fires from hot work to remove sea fastenings are a constant danger.

Implementation of comprehensive risk controls and procedures should include detailed task-specific appraisals, risk and hazard assessments, work permits, and toolbox meetings.

“This is the third time the ATSB has investigated ships fires that were found to be caused by hot work to remove sea fastenings,” Mr Nagy said.

“It’s important that ship crews do not underestimate the safety risk of this common activity and remain vigilant while undertaking hot work.”

“Implementation of comprehensive risk controls and procedures should include detailed task-specific appraisals, risk and hazard assessments, work permits, and toolbox meetings, Mr Nagy said.

The ATSB investigation found the flammable nature of the cargo coverings had not been adequately identified in the lead-up to the hot work and the fire watch was not instructed to monitor the area immediately below the hot work.

“Ship operators need to be mindful that the responsibility for the implementation of these controls rests with the ship’s master, especially when shore labour is involved and multiple organisations’ safety and work procedures could apply,” Mr Nagy said.

Read the final report: Fire on board the general cargo ship BBC Xingang, Newcastle, New South Wales, on 11 December 2017

The ATSB is reminding ship operators and ship manufacturers of the increased operational risk of using newly designed equipment without any redundancy plan in place.

The reminder follows the release of the ATSB’s final investigation report into the loss of propulsion on the cruise ship Norwegian Star, in the Bass Strait, 22 NM SW of Cape Liptrap, Victoria, on 10 February 2017.

Shortly after entering Bass Strait, the starboard propulsion unit—the ship’s only operational propulsion unit—failed, leaving the ship without propulsion and drifting about 22 NM SW of Cape Liptrap, Victoria.

The investigation, carried out by the Victorian Office of the Chief Investigator, Transport Safety, on behalf of the ATSB under the Transport Safety Investigation Act 2003, found the ship’s port propulsion unit had been non-operational since 24 January and that the ship had sailed from Darwin to Melbourne, via Cairns and Sydney, with just the starboard propulsion unit operational.

Victorian Chief Investigator, Transport Safety, Chris McKeown said underlying factor in the starboard propulsion unit failure was a design error in the repairs it had undergone in December.

“The December repairs included a modification resulting in insufficient clearance between the brush holder and sliprings of the propulsion unit’s AC generator,” Mr McKeown said. “Despite the manufacturer’s internal quality management system, this was not identified during the review and approval stages of the design.”

We would recommend against using newly modified equipment without redundancy.

“Overall, the design for the modifications was a proven and used concept, but the detailed design work required for its specific use on the Norwegian Star was not.”

“The decision to sail from Melbourne with only one operational propulsion unit was not in breach of any regulatory requirement, however, we would recommend against using newly modified safety critical equipment without redundancy,” Mr McKeown said.

Read the final report: Loss of propulsion on passenger cruise ship Norwegian Star, Bass Strait, near Cape Liptrap, Victoria, on 10 February 2017

The ATSB’s investigation into the derailment of a Metro Trains Melbourne (MTM) passenger train near Rushall Station in Melbourne on 6 February 2016 has been released. The investigation was conducted by the Victorian Office of the Chief Investigator, Transport Safety, on behalf of the ATSB under the Transport Safety Investigation Act 2003.

At about 1650, the passenger train was negotiating the most severe mainline curve on the metro network when the lead bogie of the second car derailed.

The ATSB found that the leading right-hand wheel of the second car climbed the outside rail of the small-radius curve. The main factors contributing to the derailment were the geometry of a rail joint and the high coefficient of friction between wheel and rail. The train was being operated within the speed limit for this curve and the manner of its operation did not contribute to the derailment.

For small-radius curves, the effective management of track condition is critical to reduce the risk of flange-climb derailment.

The derailment at this point on the curve was triggered by a lateral angular discontinuity at a mechanical rail joint, resulting in a localised increase in the wheel-to-rail lateral force. The network’s track geometry standard did not preclude the presence of such a discontinuity.

It was also found that the train’s wheel flanges and the rail’s gauge-face had low levels of lubrication. The performance of rail lubricators on the metropolitan network had diminished prior to the derailment, leading to a deficiency in lubrication on the network.

While not mandated by MTM, a check rail on this small-radius curve (installed adjacent to the inner rail) would have provided an additional defence against flange climb and derailment.

A number of other safety factors were identified that were not directly causal to this incident. They included a high tolerance on allowable track geometry deviations at low-speed mainline locations, a failure to address a wide-gauge defect on this curve, and the ineffective locating of some rail lubricators within the network.

To reduce the risk of future derailments on similar curves, MTM has undertaken a range of actions including significant changes to the management of track condition and faults and the installation of new electronic lubricators.

Read the final report: Derailment of MTM train TD1064, near Rushall Station in Fitzroy North, Melbourne, Victoria, on 6 February 2016

On 11 August 2016, track maintenance was planned in the vicinity of Ballarat Railway Station. To protect the work group, three sets of points within the work area were Blocked to prevent them being operated from the train control system (TCS).

Later that day, the points unexpectedly moved when the TCS was used to establish a route for a train to approach the area.

The investigation, carried out by the Victorian Office of the Chief Investigator, Transport Safety, on behalf of the ATSB under the Transport Safety Investigation Act 2003, found the design and coding of the TCS did not allow point Blocking-functionality for points that lay outside the selected route, but within its overlap area.

Victorian Chief Investigator, Transport Safety, Chris McKeown, said although maintenance crews are now required to isolate points equipment prior to carrying out maintenance, it is also important that TCS equipment correctly blocks field equipment according to the Train Controller’s settings.

“It’s important that those involved in the design and installation of these systems ensure that they adequately cover the functionality and performance requirements for all potential operational circumstances at any particular location.”

As a result of the incident, the TCS designers have improved their design procedures, and check and testing processes to ensure that Blocking is provided for overlap points. They have also tested and modified, where necessary, other similar TCS systems.

Read the final report: Signal control system irregularity, Ballarat, Victoria, on 11 August 2016