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

The ATSB’s investigation into the collision with terrain of a Cessna 206, registration VH-WZX, at Apollo Bay Airfield in Victoria, underlines the importance of pilots executing an early and correctly executed go-around during approach and landing.

On 31 January 2018, the pilot of VH-WZX touched down at Apollo Bay Airfield and then bounced and floated along the runway. The pilot attempted to complete the landing, but the aircraft continued to float and drift right, over the adjacent grass fly-over area, where it possibly bounced for a second time. With one quarter of the runway remaining the aircraft then touched down on the grass and bounced again.

After commencing a late go-around, the pilot did not immediately follow the go-around procedure as directed by the aeroplane flight manual. As a result, the aircraft did not climb as expected and struck the airfield boundary fence and continued flying. After striking the fence, the pilot again deviated from the aircraft manufacturer’s recommended go-around procedure and the aircraft descended and impacted a tree. The pilot then completed a left circuit for the runway and landed safely.

The incident highlights the need for pilots to anticipate, plan and execute early and correctly executed go-arounds.

ATSB Executive Director Nat Nagy says the incident highlights the need for pilots to execute an early go-around as recommended by the aircraft’s manual.

“The best way to avoid a late go-around is to anticipate and plan an early decision point for when to commence a go-around,” Mr Nagy said. “We support the advice of the Federal Aviation Administration, who suggest that if the landing cannot be made in the first third of the runway, you should execute a go-around.”

“In this instance, the go-around was not only late but was not carried out in line with the aircraft’s manual, making it harder for the aircraft to avoid obstacles and increasing the risk of collision.”

“While the outcome of the incident was fairly minor, it could have been much worse,” Mr Nagy said.

Read the final report: Collision with terrain involving Cessna 206, VH-WZX, Apollo Bay, Victoria, on 31 January 2018

For more information on when and how to execute a go-around read the FAA’s Airplane Flying Handbook, Chapter nine Approaches and Landings(Opens in a new tab/window)

The investigation into the fatal accident of a Cessna 172S has resulted in the Bureau issuing safety recommendations to the aircraft and autopilot manufacturers about providing limitations, cautions and warnings for autopilot systems and audible pitch trim movement.

The accident occurred on 8 September 2015, when a Cessna 172S was conducting a solo navigation training flight from Point Cook Airfield in Victoria. GPS data later showed the aircraft was on the third leg of the planned journey, cruising at about 3,000 ft above mean sea level, when it started to descend rapidly. The aircraft impacted rising terrain at about 2,200 ft and was destroyed. The pilot, who was the sole occupant, was fatally injured.

The investigation found that it was likely the pilot had manually manipulated the controls while the autopilot was on and engaged in a vertical mode. As a consequence, the autopilot re-trimmed the aircraft against pilot inputs, inducing a nose-down mistrim situation, which led to a rapid descent. The aircraft’s low operating height above the ground, along with rising terrain in front of the aircraft, would have given the pilot limited time to diagnose, react, and recover before impact. The investigation indicates that the pilot may have been unaware of the exact properties of the autopilot.

ATSB Executive Director, Mr Nat Nagy, said that this accident highlighted a matter of serious concern.

“...if automation is not performing as expected, then the safest option under most circumstances is for them to disengage the system...”

“It is now common for general aviation aircraft to be equipped with advanced avionics and autopilot systems,” Mr Nagy said. “And while these systems can be very useful, it is vitally important that pilots understand how the systems will react in different circumstances.”

After the accident, the flight training organisation conducted flight testing and has emphasised to their students the hazard of manually manipulating the flight controls with the autopilot engaged. They have also updated their operations manual to include warnings about the operation and function of the autopilot system - warnings that are absent in the manufacturer’s documentation.

“This is knowledge that all pilots need to possess,” Mr Nagy said. “Pilots should also be aware that if automation is not performing as expected, then the safest option under most circumstances is for them to disengage the system and fly the aircraft manually.”

The ATSB issued recommendations to the aircraft and autopilot manufacturers, calling for them to provide limitation, cautions, and warnings for autopilots and audible pitch trim movement.

Read the final report: Collision with terrain involving Cessna 172, VH-ZEW, Millbrook, Victoria on 8 September 2015

The ATSB’s report into the partial engine power loss and ditching of a Robinson R44, near Hamilton Island, Queensland, found adequate preparation and post-landing actions by the pilot lead to a positive outcome from an emergency ditching.

On 8 November 2017, passengers of a scenic flight were given a safety briefing advising them to wear their seatbelts and life jackets, which they complied. About 40 minutes into the one-hour flight, the helicopter began to lose engine power. After unsuccessful attempts to increase power, the pilot elected to conduct an autorotation onto the water.

The pilot successfully landed the helicopter on the water, shut down the engine, and applied the rotor brake. The pilot then activated the emergency locator transmitter and instructed passengers to inflate their life jackets and prepare to exit the helicopter, if necessary. The passengers and the pilot, who were uninjured, were rescued by the crew of a local vessel about an hour later.

Transport safety is a shared responsibility.
Operators, pilots and passengers all need to understand and follow safety instructions, procedures and policies.

ATSB Executive Director, Transport Safety Nat Nagy says the incident highlights the importance of pilots conducting a thorough pre-flight safety briefing and for passengers and aircraft to be properly equipped for an emergency situation.

“Transport safety is a shared responsibility,” said Mr Nagy. “Operators, pilots, and passengers all need to understand and follow safety instructions, procedures and policies.”   In this instance the combination of the emergency floatation system, passengers wearing their life jackets and the pilot’s post-landing actions resulted in a positive outcome from a potentially dangerous situation.

“Without the emergency floatation system the risk of the helicopter sinking with the passengers and pilot on board would have been far greater.”

Read the final report: Partial engine power loss and ditching involving Robinson R44, VH-WRR, 49 km N of Hamilton Island Airport, Queensland, on 8 November 2017

The ATSB’s investigation into the collision between a freight train and road-train truck reflects the ongoing concern of safety at level crossings.

The incident occurred on 11 July 2017, as a road-train was proceeding down the Cobb Highway from Broken Hill, New South Wales (NSW) toward Condobolin, NSW. The road-train was hauling two trailers, loaded with 43.7 t of road-base material. The driver knew there was a level crossing ahead, having used it on many occasions over the previous month, including multiple times that very day. The level crossing was equipped with flashing lights, an audible warning device (bell), as well as passive warning signs posted on the road approaching the crossing.

As the road-train negotiated a sweeping right-hand turn before the road straightened towards the level-crossing, the driver saw the flashing lights indicating that a train was approaching. He would later recall that the alignment of the road’s bends and the roadside vegetation meant that he did not see the flashing lights until his vehicle had travelled through the bend and was within 180 m from the crossing.  

The driver started to brake, but then assessed that the road-train might not stop in time, so he accelerated to cross ahead of the train.

It is troubling that this continues to be a problem in Australia.

The train driver saw the road-train accelerate and he sounded the locomotive’s horn. The train consisted of two locomotives and 27 wagons loaded with lead and zinc. About 100 m from the crossing, the train driver made an emergency brake application and activated the ‘emergency in progress’ alarm on the train radio. The train crew then relocated to the floor of the locomotive cab in preparation for a collision.

The train subsequently collided with the rear corner of the last trailer of the road-train, travelling a further 319 m before stopping. The train crew and the driver of the road-train were shaken but otherwise unhurt.

ATSB Executive Director, Transport Safety, Nat Nagy says that collisions at level crossings occur too frequently.

“From July 2016 to June 2017, there were 27 railway crossing collisions between trains and road vehicles,” Mr Nagy said. “That is too many.”

Although motorists are primarily responsible for avoiding a collision with a train at railways crossings, prudent road design and/or advance warning of a train’s presence at railway crossings should be considered as a strategy to lower the risk of road and rail vehicle collisions.

The ATSB report urges road and rail authorities to consider measures to enhance the awareness of motorists approaching railway crossings, especially at location with restricted sighting due to curved approach roads.

“It is troubling that this continues to be a problem in Australia,” Mr Nagy said. “The risk of continuing fatalities or serious injuries is real.”

Read the final report: Level crossing collision between freight train 8426N and road-train truck, Cobb Highway, Ivanhoe, New South Wales, on 11 July 2017