The ATSB has completed its investigation into a 2014 incident near Kilbride, New South Wales in which passengers were brought off a stranded train without adequate measures being taken to keep them safe.

At 1137 on 22 May 2014, NSW Train XPT passenger service NT33 was travelling from Paterson to Kilbride. The track is a single standard-gauge line that mostly carries a mix of passenger and freight trains, and there is a crossing loop at Kilbride to allow trains to pass each other.  As the train approached the loop at a speed of 118 kilometres an hour, the driver observed a bus at a road level crossing up ahead and realised that, beyond that, there were people on the track walking down towards him.

A disabled coal train had delayed an earlier passenger service (V938), and the passengers had been detrained to reach alternative road transport. The train crew of V938, however, had not complied with the Australian Rail Track Corporation network rules when detraining the passengers from their train.

At the time, Sydney Trains and NSW Trains were in a transitional period, assuming operation and maintenance functions that had previously been held by RailCorp. A services contract and protocols had been developed to identify the roles, responsibilities and limits of authority of personnel throughout the change, but on the day of this incident, there was confusion and assumptions among the crew as to who had done what in regards to ensuring appropriate track protection.

All of this had resulted in the crew unknowingly placing the passengers in the path of the oncoming NT33.

We cannot afford to make assumptions when it comes to safety.

The driver of NT33 immediately made an emergency brake application and sounded the horn continuously. The train finally came to a stand approximately 80 m short of the people.

There were no reported injuries as a result of the incident, but this near-miss shows the importance of strict adherence to recognised detraining and track protection procedures when transferring passengers from a stranded train to a safe place.

The investigation also found that key operational staff in NSW Trains and Sydney Trains continued to operate under RailCorp legacy systems, even though documented transitional arrangements had re-established lines of responsibility and authority. This misunderstanding of roles, responsibilities and limits of authority by operational employees likely contributed to inadequate communication between critical safe working positions.

ATSB Executive Director of Transport Safety Nat Nagy says it is essential that safety systems are fully developed and understood by all.

“Thankfully, no one was injured,” Mr Nagy said. “But this shows that we cannot afford to make assumptions when it comes to safety.”

Read the final report: Near hit with detrained passengers on track, at Kilbride, New South Wales, on 22 May 2014

This serious incident involving an Airbus A320 on approach to Perth Airport has illustrated ATSB’s ongoing safety concerns in relation to pilots not effectively managing their aircraft’s flight path when unexpected events arise during the approach to land.

This incident occurred on 19 February 2016, when a scheduled passenger service was arriving from Denpasar, Indonesia. During the cruise, the captain’s flight management and guidance computer (FMGC1) had failed, and the flight crew had elected to use the first officer’s duplicate systems.

The flight crew were conducting an instrument landing system (ILS) approach to Perth Airport. They made a number of flight mode changes and autopilot selections - normal for an ILS approach with all aircraft operating systems available, but some of which relied on data from the failed FMGC1.  As a result, the autothrust system commanded increased engine thrust and the crew, who had not expected this response, elected to conduct a go-around. An increased crosswind then prompted air traffic control to effect a change of runway to a runway without a precision instrument approach procedure.

The approach and landing phases of flight are amongst the highest of workload for flight crews…

The unresolved system failures, the conduct of the go-around, and the subsequent runway change all resulted in a significant increase in cockpit workload. This, combined with the crew’s unfamiliarity and preparation for the non-precision instrument approach to the new runway, hampered their management of the next descent.

During the approach to the new runway, the crew descended the aircraft earlier than prescribed, but believed that they were on the correct flight path profile. They became concerned that they could not visually identify the runway, and focused their attention outside the aircraft. This distraction meant that the crew were not effectively monitoring the descent and the captain descended the aircraft below the segment minimum safe altitude.

As the aircraft continued to descend, the air traffic controller received a “below minimum safe altitude” warning for the aircraft. The air traffic controller alerted the crew to their low altitude and instructed them to conduct a go-around. The crew then conducted another approach and landed without further incident.

ATSB Chief Commissioner Greg Hood said that the approach to land is one of the most critical phases of flight, and stressed the importance of flight crews understanding their aircraft systems and adhering to cockpit control, monitoring and communication procedures to ensure a stabilised approach during the approach and landing phases of flight.

“The approach and landing phases of flight are amongst the highest of workload for flight crews, and domestically and internationally where we see the highest accident rate” Mr Hood said. “It’s a complex operation at the best of times, but when something unexpected occurs such as a failure of an aircraft system in-flight, it can add substantially to flight crews’ workload. It is critical that flight crew fully understand their aircraft systems and how they will respond in a degraded mode, and adhere to cockpit protocols and procedures to ensure a stabilised approach resulting in a safe landing. In this case, there was considerable added complexity for the flight crew as a result of adverse weather, and an air traffic control change to a runway without a precision approach.”

“The ATSB urges all flight crew to ensure that they understand their aircraft systems, and how the aircraft will respond in a degraded mode, and to adhere to cockpit protocols and procedures to ensure a safe approach and landing. If there’s any doubt or confusion, or if the stable approach criteria is not being met, communicate it, and never hesitate to conduct a go-around.”

Read the final report: Descent below segment minimum safe altitude during a non-precision instrument approach involving Airbus A320, PK-AXY, 17 km west-south-west of Perth Airport, Western Australia, on 19 February 2016

While experiencing high workloads, a flight crew member’s attention can channel or tunnel towards a single task, drawing or distracting their attention away from their other task demands.

An incident involving a JetGo registered Embraer ERJ-135 at Middlemount Airport in Queensland demonstrates the impact this can have during a part of a flight traditionally associated with the highest accidents rate—approach and landing.

On 8 August 2017, during the final approach leg, the aircraft descended below its desired approach path and landed prior to the selected aim point, resulting in its main landing gear tyres colliding with two runway threshold lights just before landing.

While there were no injuries or damage to the aircraft as a result of the incident, its descent below the desired approach path and its collision with terrain, however small, were cause for concern.

The impact of high workload can have a significance impact on any flight crew and it affects needs to be managed and monitored systematically...

Stuart Godley, Director Transport Safety at the ATSB says the impact of workload can be deceptive with an individual not realising it has increased until it has a reached a high level. “The best way of managing workload is to reduce the level of work demands and distractions,” said Godley. “However, in this incident the flight crew were managing a number of different factors in addition to the approach and landing.”

The ATSB investigation found the flight involved a captain under line training, who was operating a new aircraft type with new operating procedures. This was compounded by the high workload associated with the training, and the existing workload demands of approach and landing. In addition, the investigation found an absence of approach slope guidance at the Airport.

“The impact of high workload can have a significance impact on any flight crew and it affects needs to be managed and monitored systematically, especially for less experienced flight crews or those operating a new type of aircraft,” Godley said.

In response to the investigation, the operator has have advised the ATSB they have taken various proactive safety actions to reduce the risk of a similar incident in the future, such as line training flights to no longer operate to Middlemount Airport, and updating their flight crew operating manual (FCOM) to include material on runway visual illusions. The flight crew also underwent further training in approaches without a visual approach slope guidance.

The ATSB is encouraging operators and flight crews to consider the steps they can take to ensure they manage high and increased workloads so they can make appropriate decisions to ensure a safe landing.

“Making appropriate decisions and maintaining a stable approach profile is one of our key messages in our SafetyWatch list of concerns,” Godley said.

Read the final report: Collision with runway lighting involving Embraer ERJ-135, VH-JGB, Middlemount Airport, Queensland, on 8 August 2017

The ATSB has released its latest corporate plan, outlining the agency’s priorities, deliverables and challenges for the coming four years.

Greg Hood, Chief Commissioner and CEO of the ATSB, acknowledged that the plan was an important compass for the agency. “This is a substantial and outcome-focussed blueprint for the ATSB’s future,” said Mr Hood. “We are pursuing a significant reform agenda designed to enable better resource allocation and utilisation across the agency.”

In demonstrating increased effectiveness, the ATSB will become more selective in how it allocates resources towards investigating those accidents and serious incidents that have the greatest potential for safety learnings and enhancements. Concurrently, the ATSB will expand its capacity to improve transport safety outside of these traditional investigations, through safety issue investigations, through greater interaction with operators and regulators, with data and other intelligence in its possession, and through amplified communications, education and promotion.

“The ATSB’s greatest resource continues to be its people,” said Mr Hood. “Our transport safety investigators are world-class, and we are working hard to attract, develop, and retain the best people – people who have our shared values, passion and drive to improve transport safety for all Australians.”

Read the ATSB’s latest corporate plan.

An ATSB investigation report has emphasised the need for operators to heed the advice of aircraft manufacturers with regards to maintenance and upgrades to their fleet.

On 13 December 2016, a B200 King Air aircraft was conducting a visual approach to Moomba Airport in South Australia when the pilot observed the left engine fire warning activate. The pilot shut down the left engine, but omitted to feather the propeller. The additional drag caused by the windmilling propeller combined with the aircraft configuration for landing while in a right turn, requiring more thrust than was available. The aircraft landed in the sand to the left of the runway threshold and, after a short ground roll, spun to the left before coming to rest. There were no injuries, but the aircraft was substantially damaged.

No engine fire damage was found, which indicated the fire warning had almost certainly been a false alarm. The aircraft manufacturer had previously published a service bulletin for the optional replacement of the engine fire detection system with a system less susceptible to false warnings. The operator, however, who had limited experienced with false engine warnings in their fleet, elected not to replace the system on the aircraft.

The ATSB also found that the pilot had not received the operator’s published syllabus of training for that aircraft. Instead, a tailored training program was delivered based on the pilot’s experience on the C90 King Air and taking into account advice the operator received from the Civil Aviation Safety Authority (CASA). This training did not cover all the elements required under the Civil Aviation Safety Regulations.

As a result, CASA will be taking steps to refresh industry and its own officers’ knowledge of particular terms and concepts within the flight crew licencing regulations, so as to remove any doubt regarding their interpretation and applicability.

Read the final report: Engine shutdown and collision with terrain involving Beech Aircraft Corporation B200, VH-MVL, Moomba Airport, South Australia, on 13 December 2016

The management company of the Spirit of Tasmania II has implemented a raft of changes in response to an ATSB investigation MO-2016-001 into a mooring incident at Station Pier, Melbourne, in January 2016.

The changes will ensure that weather monitoring and mooring systems and procedures are regularly checked and verified for changing weather conditions. These will reduce the safety risks for ships with large numbers of passengers.

Spirit of Tasmania II was loading cargo, vehicles and passengers at Station Pier on 13 January 2016 when, just before 6pm, strong wind gusts blew the ship away from the wharf.

After breaking away, the stern swung around until the ship was 90 degrees to the wharf, parallel to nearby Port Melbourne Beach with a possibility of grounding.

ATSB Chief Commissioner Greg Hood says the investigation found a band of severe thunderstorms passed across the location of Spirit of Tasmania II, with little warning.

“With the ship’s bridge unattended during the port stay, none of its crew saw indicators of the approaching storm until just before the breakaway,” Mr Hood said.

“The crew responded swiftly, controlling the ship’s movement using its thrusters and main propulsion machinery. With two tugs assisting, it was returned to the wharf just after 7pm.”

The ship suffered minor damage to its lower bow ramp and bow doors. Shore infrastructure suffered extensive damage to the elevated roadway and ramp arrangement on the wharf and minor damage to wharf structures. No one was injured.

Since the incident, the ship’s managers, TT-Line Company, advised the ATSB of changes to shipboard weather monitoring and notification arrangements along with changes to heavy weather and mooring procedures.

Mr Hood welcomed the changes including weather triggers for increased shipboard readiness and immediate notification of weather warnings.

“In addition, there will be access to the Bureau of Meteorology (BoM) website from the bridge, changes to on-board wind speed alarm settings and a requirement for all mooring lines to be held on the winch brakes,” he said.

“TT-Line also engaged external marine consultants to examine and recommend any alterations to berthing arrangements and infrastructure at Station Pier.”

The ATSB has issued one recommendation to TT-Line to complete safety action to adequately address the safety issue with respect to mooring at Station Pier. TT-Line has 90 days to respond to the ATSB’s safety recommendation.

Further, the Victorian Ports Corporation (Melbourne) advised the ATSB that Melbourne vessel traffic service will broadcast BoM weather warnings on VHF channel 12. All masters of ships in port waters, including at berth or anchorage, are to ensure a listening watch is maintained at all times.

Also, the BoM has advised the ATSB that it continues to upgrade its marine weather services, including a one-stop webpage on its website for improved education, information and accessibility to marine and ocean services.

Read the final report: Breakaway of Spirit of Tasmania II, Station Pier, Port Melbourne, Victoria, on 13 January 2016

The ATSB has today released an update into the tragic accident involving a B200 King Air aircraft that collided with a retail facility at Essendon Airport on 21 February this year. Sadly all four passengers and the pilot died in the accident.

ATSB Chief Commissioner Greg Hood said ATSB investigators have done an extensive amount of work to date.

“Investigators have gathered and assessed a large volume of evidence such as CCTV footage and witness statements. The team has also inspected the engines in close consultation with the manufacturer,” Mr Hood said.

“The aircraft’s fire-damaged CVR was retrieved and transported to the ATSB’s technical facilities in Canberra for examination and download.

“While the CVR was successfully downloaded, no audio from the accident flight was recorded. All the recovered audio was from a previous flight on 3 January 2017. The ATSB is examining the reasons for this.”

Mr Hood said that while the team is diligently assessing the physical and digital evidence, the considerable damage to the aircraft is presenting challenges.

“The extensive damage caused by the collision and post-impact fire has meant investigators are yet to determine a clear picture of the causal factors behind the accident and loss of life,” Mr Hood said.

“I offer my deepest sympathies to the families and loved ones of those on board the aircraft. Every effort is being made to determine the cause of this tragic accident.”

This update does not contain findings. The ATSB will present the findings of its investigation in the final report, due out in around 12 months. Further updates will be provided if significant information comes to hand.

If the ATSB identifies any safety issues during the course of the investigation, it will immediately bring them to the attention of relevant operators and authorities for safety action.

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

As the range of products using batteries grows, the potential for in-flight issues increases.

On a recent flight from Beijing to Melbourne, a passenger was listening to music using a pair of her own battery-operated headphones.

About two hours into the flight while sleeping, the passenger heard a loud explosion. “As I went to turn around I felt burning on my face,” she said. “I just grabbed my face which caused the headphones to go around my neck.

“I continued to feel burning so I grabbed them off and threw them on the floor. They were sparking and had small amounts of fire.

“As I went to stamp my foot on them the flight attendants were already there with a bucket of water to pour on them. They put them into the bucket at the rear of the plane.” The battery and cover were both melted and stuck to the floor of the aircraft.

Flight attendants returned to check on her wellbeing. For the remainder of the flight, passengers endured the smell of melted plastic, burnt electronics and burnt hair. “People were coughing and choking the entire way home,” the passenger said.

The ATSB assessed that the batteries in the device likely caught on fire. The ATSB reminds passengers using battery-powered devices that:

• batteries should be kept in an approved stowage, unless in use
• spare batteries must be in your carry-on baggage NOT checked baggage
• if a passenger’s smart phone or other device has fallen into the seat gap, locate their device before moving powered seats
• if a passenger cannot locate their device, they should refrain from moving their seat and immediately contact a cabin crew member.

More information about Travelling safely with batteries and portable power packs(Opens in a new tab/window).

Other ATSB news stories and investigation reports about lithium-ion batteries:

• Aviation incident sparks lithium battery warning
• Personal electronic device fire in-flight involving Boeing 747
• Crew’s prompt in-flight response to smoking device.