A reminder that a failure to follow procedure, such as functional checks, can result in unintended consequences.

A lock-out pin not removed after maintenance meant the crew of an Airbus A320 landed at Sydney with reverse thrust inadvertently deactivated. An ATSB investigation found a maintenance team had deviated from procedures, probably due to operational pressure.

Prior to the incident, the aircraft had undergone a three-day maintenance check at a facility in Brisbane. Two days in, the engineers identified that the horizontal stabiliser actuator required replacement, which added a half day of work to the schedule. To recover the lost time, the team was organised to begin work at 0400 the following day. Then the aircraft departure time was brought forward, and the engineers were instructed to complete the maintenance by the end of first shift. Many of the engineers worked through their lunch breaks to ensure they could complete the maintenance on time.

While working under the compressed schedule, engineers deviated from the written procedures, and the incorrect lockout pin was installed and then not removed later. As a result, the aircraft was returned to service with the thrust reverser system inadvertently deactivated.

There was no damage to the aircraft, or injuries as result of the incident.

The safety message from this investigation is that functional checks are the last line of defence in maintenance work. Failure to follow procedures, such as functional checks, can result in unintended consequences. Additionally, it is imperative that aircraft maintenance engineers feel empowered to stop a process when they observe procedural violations or foresee that an error is likely to occur.

Read the final report: Engine thrust reverser malfunction involving Airbus A320, VH-VGZ, Sydney Airport, New South Wales, on 20 September 2018

A livestock carrier's contact with a wharf shows the importance of sharing knowledge. In this case, the harbour master and the pilot were unaware of limitations with fender heights.

The ATSB’s investigation into the contact with wharf by livestock carrier Angus Express at the port of Broome, Western Australia, highlights the challenging situations that marine pilots may encounter, and why it is important that local knowledge is captured and shared.

On 20 April 2018, the Angus Express had just completed a voyage from Singapore, and was expected to load cattle. As the vessel came into berth, the weight of the ship against the forward Yokohama fender forced it to pass under the fender posts, which resulted in the ship’s bow moving towards the wharf. Shortly after, an overhanging scupper protrusion made contact with the fender post.

The pilot thought that the ship had pivoted on the Yokohama fender and instructed the tug to push forward again, resulting in the forward Yokohama fender once again passing underneath the fender posts. The ship’s bow again moved towards the wharf, and the scupper protrusion again made contact with the fender post. The harbour master subsequently attended and found minor damage to the ship’s superstructure.

Marine pilots, in particular, may encounter operational parameters outside normal limits.

The ATSB investigation found that those fender posts were shorter than others in the port, and at certain tide heights, could be forced down by a ship. A former pilot at the port advised that they had been aware of this, but that knowledge had never been documented or shared. 

As a result of this occurrence, the Kimberley Ports Authority has implemented guidelines for berthing and being alongside when using Yokohama-style fenders at times of limiting low water levels. Also, harbour masters and pilots are to conduct risk assessments for circumstances such as tug shortages, vessel manoeuvring issues and tidal levels.

The safety message from the accident is the importance of capturing and sharing lessons learned from experience. Marine pilots, in particular, may encounter operational parameters outside normal limits. Capturing the lessons through proper reporting process and sharing information through training and awareness can help to reduce risk and avoid future occurrences.

The challenges surrounding marine pilotage is one of the ATSB’s SafetyWatch priorities. Visit our website for important safety messages and advice.

Read the final report: Contact with wharf by livestock carrier Angus Express, at Broome, Western Australia, on 20 April 2018

The forced landing of a Cessna 172 into scrubland south-west of Kalgoorlie Airport, Western Australia, following fuel exhaustion again highlights the need for continued pilot education on the risks and controls associated with fuel management.

The Cessna 172M, registration VH-TUX, had been tasked to conduct fire-spotting operations in the Lake Johnstone area near Kalgoorlie on 5 January 2018. During the flight, the engine speed began to steadily reduce toward idle. The pilot switched between fuel tanks and adjusted the mixture and throttle settings. This resulted in the engine speed momentarily increasing before returning to idle.

Preparing for a forced landing on a dirt road, the pilot realised the aircraft’s glide range would be insufficient and identified an area of less dense scrub and landed the aircraft with minimal damage.

The pilot’s flying instructor experience instructing student pilots on the procedures for an engine restart and practice forced landings likely aided in managing workload during the emergency and led to the successful forced landing.

The investigation found the pilot’s in-flight fuel management resulted in insufficient endurance to safely conduct the planned flight and the aircraft exhausting its useable fuel supply.

Fuel starvation and exhaustion events continue to be reported to the ATSB

The aircraft had recently been refitted with wings sourced from another Cessna 172M. The replacement wings were fitted with smaller capacity tanks of 144 litres, compared to the previous 182 litres. Despite a number of opportunities to identify the change to the aircraft’s endurance, the pilot, who had flown VH-TUX on numerous occasions prior to its fitment of new wings, did not detect the reduced fuel capacity. 

During the accident fight, the pilot observed a steady decrease in the indications on the fuel gauge, but the pilot discounted the accuracy of the indications. The pilot’s in-flight fuel management was likely based on the expectation of the aircraft’s endurance, rather than crosschecking the expected fuel burn against the fuel burn achieved during flight at the 30-minute intervals required under the operator’s standard operating procedures.

Further, the pilot’s pre-flight planning was inconsistent with both the regulatory requirements for flight planning and preparation, and the operator’s own electronic flight bag administration and in-flight fuel management procedures.

Fuel starvation and exhaustion events continue to be reported to the ATSB. The ATSB’s safety message from this investigation the importance for pilots to continue to educate themselves on the risks and controls associated with fuel management.

Methods for cross-checking fuel on board before flight are published by the Civil Aviation Safety Authority in Civil Aviation Advisory Publication 234-1(2): Guidelines for aircraft fuel requirements(Opens in a new tab/window).

Case studies for pilots to learn about fuel management related accidents have been published by the ATSB in Avoidable Accidents No. 5 – Starved and exhausted: Fuel management aviation accidents.

Read the final report: Fuel exhaustion involving Cessna 172M, VH-TUX, 72 km south of Kalgoorlie-Boulder Airport, Western Australia, on 5 January 2018

A Cessna 172 was flying from Queensland to New South Wales when it entered an area of reduced visibility, including low cloud, fog and drizzle. The aircraft diverted off the initial track and was last seen disappearing into cloud heading inland. A short time later, the aircraft collided with terrain and the pilot was fatally injured.

The ATSB found that the decision to depart on the flight had placed the pilot at risk of encountering conditions of reduced visibility. On entering those conditions, the pilot likely became spatially disoriented, resulting in a loss of control and a collision with terrain. The ATSB also found that the pilot was likely under some degree of self-imposed pressure to continue with the flight, despite the inclement weather conditions.

Weather-related accidents remain one of the most significant causes of fatal accidents in general aviation.

“The ATSB’s safety messages from this investigation are clear: visual flight rules pilots should conduct thorough pre-flight planning to avoid the possibility of flying into bad weather. They should also make alternate plans in case weather deteriorates, and make timely decisions about diverting or turning back,” said ATSB Executive Director Transport Safety Mr Nat Nagy.

“If visual flight rules pilots do find themselves in deteriorating weather and become disoriented or lost, they should seek whatever help is available including contacting air traffic control. This simple action has averted potential disaster in many instances.”

Weather-related accidents remain one of the most significant causes of fatal accidents in general aviation. Inflight decision-making is one of the ATSB’s SafetyWatch priorities, particularly regarding pilots flying with reduced visual reference.

Among the advice that SafetyWatch provides, the use of ‘personal minimums’ checklists is key. VFR pilots should use a checklist to help control and manage flight risks by identifying risk factors that include marginal weather conditions and only fly in environments that do not exceed their capabilities.

This report highlights an ongoing safety issue in aviation. Check out our SafetyWatch page, Inflight decision making, for more information on this important subject.

Read the final report: VFR into IMC and loss of control involving Cessna 172, VH-FYN, 13 km north-north-west of Ballina, New South Wales, on 16 June 2017

Multiple factors combined to result in an incident in which a container on a freight train collided with station infrastructure.

The ATSB’s investigation into the incident yielded important safety messages for rail infrastructure managers and maintainers, rail operators, and rail safety workers involved in the loading and examination of train services.

The incident occurred on 16 January 2018, as freight train 2BM9 passed through Maitland Railway Station at approximately 0748. The trailing edge of one of the containers on the train collided with the verandah gutter mounting brackets on Platform 1. Two lengths of the verandah gutter dropped to the surface of the platform. Although there were some people on the platform at the time, no one was in the immediate area of the collision, and no injuries were reported. 

The ATSB investigation found that, while the track owner had scheduled and undertaken clearance inspections at Maitland, these inspections had not detected that the increase in track height over time had reduced the available clearance and infringed on both the design measurements and track owner’s clearance specifications.

In addition to the increase in track height and clearance reduction, a loading irregularity on the train also existed at the time of the collision, where the container was not correctly secured to its wagon.

Ensure that processes and requirements are documented, understood, and adhered to.

The investigation found that the train operator had not documented its process for loading checks expected from the loading operations staff when securing containers to wagons.

The ATSB found these two elements combined to result in the collision between the freight train container and the verandah guttering at the Station.

This incident shows the importance of ensuring that processes and requirements are documented, understood, and adhered to.

Both the train operator and the rail infrastructure manager have taken proactive safety action to address the issues and reduce the likelihood of a recurrence.

Read the final report: Loading irregularity on train 2BM9, Maitland, New South Wales, on 16 January 2018

The accident occurred on 18 November 2016, when a Robinson R44 II helicopter was on a charter flight with one pilot and one passenger on board. About 41 km north-west of Mossman, Queensland, while flying above Mount Windsor National Park, the helicopter impacted dense rainforest after one of the main rotor blades struck and separated a section of the tailcone.

The helicopter broke-up into multiple fragments and descended through the forest canopy, and was subject to a post-impact fire.

The Australian Maritime Safety Authority’s Joint Rescue Coordination Centre detected a signal from the helicopter’s emergency locator transmitter (ELT), and the subsequent search and rescue operation was able to locate the wreckage and recover the seriously injured pilot. The passenger was fatally injured.

The activated transmitter led to the rescue of the pilot, who might otherwise have not survived.

The activation of the emergency location transmitter on impact resulted in the discovery of the accident site by the search and rescue helicopter about 1 hour and 48 minutes after initial detection of the ELT signal. The pilot may otherwise have not survived.

The ATSB investigation of the wreckage indicated there was low engine power and rotor speed at the time of the tail strike, which was likely the result of a main rotor blade stall event. The ATSB was unable to determine what precipitated the blade stall event.

The ATSB also found that the helicopter was likely operating in at least moderate turbulent flight conditions, which were not forecast.

It could not be determined if the wind and associated turbulence contributed to the accident, however it is important for pilots to consider the effect of the terrain on the weather forecast, which could result in a helicopter not achieving its predicted performance.

This accident highlights the importance of impact-activated ELTs, and the ATSB advocates for GPS encoded transmitters be used.

Read the final report: In-flight break-up involving a Robinson R44, VH-ZNZ, 41 km north-west of Mossman, Queensland, on 18 November 2016

The ATSB research report A review of the effectiveness of emergency locator transmitters in aviation accidents provides guidance to owners and operators on how they can maximise the reliability and effectiveness of emergency locator transmitters.

The ATSB is urging pilots to take time before they take off to consider their options and actions in the event of a partial power loss. Self-briefing on this subject before take-off can reduce the decision-making load if a power loss does occur.

The ATSB’s investigation into the fatal accident of a DH82A Tiger Moth aircraft reflects the challenging situation faced during a partial power loss shortly after take-off.

The accident occurred on 28 December 2015, when the Tiger Moth departed Pimpama Airfield, Queensland to conduct a 20-minute local adventure flight with the pilot and one passenger. About 27 seconds after take-off, the pilot observed a change in engine noise and a reduction in engine RPM. He reported that he retarded and then fully advanced the throttle, but the engine only returned to a similar lower power condition.

The pilot assessed that, as the aircraft still had partial power, he would make a left turn and return to the airfield to land. Following this decision, the aircraft’s performance deteriorated further so he attempted to perform a forced landing in a cleared area. Soon after he started the turn, however, the aircraft stalled and began to enter a left spin. The pilot recalled applying full right rudder in an attempt to stop the spin but the aircraft collided with the ground.

The passenger, who was in the Tiger Moth’s front seat, was fatally injured, while the pilot sustained serious injuries.

A partial power loss presents a more complex scenario than a complete power loss.

The ATSB investigation was unable to determine the reason for the partial power loss, but found that when the aircraft entered the spin, there was insufficient height to recover before ground contact.

A partial power loss presents a more complex scenario than a complete power loss, where a forced landing is inevitable. When faced with a partial power loss, pilots must evaluate whether or not they should try to return to the airfield.

Pilots also have to take into account the possibility that power may continue to deteriorate, may stay at the same reduced level, or may return to normal.”

When an emergency landing is required, flying the aircraft in a controlled manner, wings level and at the recommended glide speed has a better survivability outcome than when control of the aircraft is lost.

The dangers of partial power loss after take-off are the subject of the ATSB’s publication Avoidable Accidents No. 3 - Managing partial power loss after take-off in single-engine aircraft. The booklet provides information and advice regarding this complex scenario.

Read the final report: Loss of control and collision with terrain involving de Havilland DH82A Tiger Moth, VH-UZB, Pimpama Airfield, Queensland, on 28 December 2015

The ATSB is urging crewmembers to adhere to procedures that are created to keep them safe after a serious incident on a bulk carrier ship left two men seriously injured.

The ATSB has completed the investigation into how two crewmembers on board the bulk carrier Shanghai Spirit suffered serious injuries after a scaffolding tower fell.  

This serious incident occurred on 29 January 2017, when the 140 m geared bulk carrier was anchored in Keppel Bay, about 15 nautical miles north-east of Port Alma Queensland. Deck crewmembers were using a mobile scaffold tower to conduct painting and routine touch-up work in the cargo holds. As the scaffold tower was moved with two unsecured crewmembers still on the upper tiers, it became unbalanced and toppled forward onto the deck. 

On hitting the deck, the scaffold tower came apart and the two crewmembers were entangled in the components. Emergency services were notified of the incident, and a rescue helicopter was dispatched, making two trips out to the vessel to transport the men to hospital. Both men had to remain in hospital for several days before they could be released.

This is not the first such occurrence that the ATSB has investigated.

This serious incident highlights the importance of adhering to procedures that assure safety, as well as the value of effective supervision, with the investigation finding that, contrary to established procedures, two crewmembers remained on an unsecured scaffold tower when it was moved across the floor of a cargo hold.

As a result, the top-heavy and unstable scaffold tower toppled and fell. The crewmembers themselves were unsecured, without the required safety harness and lines.

This is not the first such occurrence that the ATSB has investigated. Similar occurrences in 2003 and 2009 also resulted in serious injuries and, in one instance, the death of a crew member.

Owners, operators and crewmembers are reminded to plan and undertake risk assessments for assigned tasks in order to identify any shortcomings in procedures and required risk-mitigation measures.

Read the final report: Fall from height and serious injuries to crewmembers on board Shanghai Spirit, near Port Alma, Queensland, on 29 January 2017

A fatal collision with terrain at a private airfield has highlighted the importance of obtaining all relevant information about local wind conditions before commencing an approach.

The accident occurred on 20 January 2018, when a Cessna 182 carrying a pilot and passenger was completing the journey from The Vale Airstrip to a private airfield at Tomahawk, Tasmania. The pilot conducted a number of orbits and then approached the runway.

The pilot was unaware, however, that his choice of approach direction exposed the aircraft to a tailwind that significantly increased the groundspeed on final approach. This resulted in insufficient landing distance. Additionally, the final approach was not stable. In combination with the tailwind, this resulted in the aircraft coming in too high and fast.

The aircraft touched down more than halfway along the runway – well beyond the runway threshold – and it bounced several times. In response, the pilot commenced a go-around, but the aircraft collided with a tree beyond the end of the runway, and it impacted the ground. The passenger was fatally injured, and the pilot sustained serious injuries. The aircraft was substantially damaged.

The investigation found that the pilot had not identified the direction of the local surface wind, although it was forecast. There was no windsock at the airfield, but there were a number of other means by which the pilot could have assessed the wind prior to commencing the approach.

If a safe landing cannot be assured, the pilot should abort the landing and go-around early.

ATSB Executive Director Transport Safety, Mr Nat Nagy said the investigation found that the selected landing direction meant that the aircraft had an increased tailwind and groundspeed on approach.

“The investigation also found that the final approach path was unstable,” Mr Nagy said. “What that meant was that the aircraft was both high and fast when it was coming into land which meant it landed well down the runway and bounced during that landing.”

The investigation also found that the go-around was initiated at a point from which there was insufficient distance remaining for the aircraft to climb above the tree at the end of the runway in the landing flap configuration and tailwind conditions.  

“The ATSB’s safety message out of this investigation is to remind all pilots that they should determine the local weather conditions, including wind direction and strength, prior to commencing an approach,” Mr Nagy said. “Most importantly, if a safe landing cannot be assured, the pilot should abort the landing and go-around early.”

Read the final report: Collision with terrain involving Cessna 182, VH-TSA, at Tomahawk, Tasmania, on 20 January 2018