On 13 March, 2017, a Qantas Airways Boeing 737 was travelling to Canberra on a scheduled passenger flight from Perth Airport, Western Australia. There were two flight crew, five cabin crew, and 177 passengers on board.

As the aircraft began descending towards Canberra Airport, it encountered increasing turbulence, and the flight crew switched on the ‘Fasten Seat Belt Sign’, calling for cabin crew members to be seated within one minute of the announcement. The crew began to move towards their seats, securing the cabin as they went.

At 22,000 feet, an abrupt change in the direction of the wind resulted in the aircraft airspeed increasing towards the maximum allowable operating speed.

To prevent an overspeed, the pilot flying applied backpressure on the control column, so as to override the autopilot. This was a common practice for B737 flight crews at Qantas, and the first officer recalled that this was part of initial training for the B737. The expected outcome was that the autopilot would revert to a different mode and raise the aircraft’s nose.

A cabin crew member who had not yet reached her seat felt the cabin floor drop and then quickly come up

In this case, however, the autopilot disengaged, and the aircraft moved abruptly. A cabin crew member who had not yet reached her seat felt the cabin floor drop and then quickly come up. The force of the aircraft’s movement resulted in her fracturing her leg, while a second cabin crew member fell and hit her head on a trolley.

The injured crew member was given first aid and the aircraft landed without further incident. Paramedics met the aircraft to attend to the two injured cabin crew.

The method of intervention by the pilot was understandable, and consistent with previous responses of other flight crew in similar situation. Modification of the autopilot, however, had inadvertently left the aircraft vulnerable to this type of scenario.

Qantas has taken steps to address the dangers that this manoeuvre can create. They have issued a safety information notice, warning of the potential dangers of that approach.

The report also highlights the manufacturer’s preferred use of speedbrakes to prevent overspeed. Boeing has advised that they are considering a revision to the overspeed guidance in the 737 flight crew training manual.

“It’s encouraging to see organisations taking steps to address problems as they emerge,” said Nat Nagy, the ATSB’s Executive Director, Transport Safety. “This method of intervention to prevent overspeed had been used 20 times in the past six years, but this occurrence and the resulting investigation has provided an opportunity to make transport even safer.”

Read the final report: Flight path management occurrence involving Boeing 737, VH-VZZ, near Canberra Airport, Australian Capital Territory, on 13 March 2017

The ATSB’s investigation into a main rotor tip strike involving a Eurocopter AS350-BA VH-PHU, 9 km WNW of St. Leonards (ALA) in Victoria found the pilot did not notice an obstacle encroaching into the helicopter landing site (HLS).

The pilot of the Eurocopter approached the Jack Rabbit Vineyard HLS (a tennis court) on 4 July 2017. This was the first time the pilot had used the site. During the approach the pilot identified the key boundaries of the site, including a brick wall at its southern end, but did not notice vegetation intruding into the site.  

Believing that another helicopter was moving into the site, the pilot slowly hover-taxied the helicopter towards the south-west corner of the site. The tips of the helicopter’s main rotor blades struck the vegetation. The pilot was able to safety land and reposition clear of the obstacle. The incident resulted in damage to all three main rotor tips.

All pilots, no matter how experienced, are not immune to errors and experience alone will not protect them from an accident.

ATSB Executive Director Transport Safety Nat Nagy says the incident reinforced the need for pilots to have strong situational awareness when flying near obstacles.

“Strong situational awareness is critical to maintaining aircraft safety, especially when flying in new and confined locations,” Mr Nagy said. “To get a good understanding of a landing site, pilots are encouraged to do a 360-degree reconnaissance.”

“In this instance, the pilot did an abbreviated reconnaissance and didn’t notice an obstacle that needed to be avoided.”

The ATSB investigation found this choice of reconnaissance may have been the result of the pilot’s over-confidence in their pre-planning and flying ability.

“All pilots, no matter how experienced, are not immune to errors and experience alone will not protect them from an accident,” Mr Nagy said.

For insights into how accidents can happen to experienced pilots, download a copy of the ATSB publication, Avoidable Accidents No.6 – Experience won’t always save you: Pilot experience is not always a protection against an accident, from the ATSB website.

Read the final report: Main rotor tip strike involving Eurocopter AS350-BA, VH-PHU, 9 km west-north-west of St. Leonards (ALA), Victoria, on 4 July 2017

The ATSB’s investigation into foreign object damage involving an Airbus A320, VH-VGY at Auckland International Airport on 27 October 2017 found the aircraft’s right engine was damaged by metal debris from a clipboard left in the engine cowling.

After the loading of VH-VGY, the clipboard was left on the right engine cowling to protect it from the weather, with the intent of it being collected later. This did not happen. The presence of the clipboard was noticed during a ‘duty of care’ walk around but not reported.

ATSB Executive Director Transport Safety Nat Nagy says the incident highlights the need for everyone operating near the aircraft to take ownership of reporting foreign objects.

It is easy to think that someone else will report or remove a foreign object but that kind of thinking usually just increases the risk that it won’t get done.

“It is easy to think that someone else will report or remove a foreign object, but that kind of thinking usually just increases the risk that it won’t get done.” Mr Nagy said.

In this instance, staff recalled the need to collect the clipboard as VH-VGY was taxiing. Staff returned to where the aircraft was loaded, saw paper debris on the ground, and realised it had been left in the engine.

After the flight crew were notified, they checked their engine instruments and saw no abnormal indications. However, upon learning that sheared metal had also been found, the aircraft returned to Auckland. An engineering inspection found paper throughout the engine and minor damage to the fan blade and attrition liner.

Both Jetstar and the ground handling operator, Aerocare, have taken steps to educate staff of their reporting responsibilities around foreign objects. Jetstar has also updated their aircraft dispatch procedures to provide more detailed information about aircraft checks and responsibilities.

Read the final report: Foreign object damage involving Airbus A320, VH-VGY, Auckland International Airport, New Zealand, on 27 October 2017

The ATSB’s investigation into a collision with terrain of an amateur-built Sling 4 aircraft at Caloundra aerodrome, in Queensland, found that due the use of incorrect weight and balance data, the flight was conducted with the centre of gravity aft of its rear limit.

Before its flight on the morning of 12 August 2017, the pilot used the average or standard weights of each occupant to calculate the aircraft’s weight and balance with its electronic flight instrument system.

ATSB Executive Director Transport Safety Nat Nagy says that to reduce the risk of overloading the Civil Aviation Safety Authority recommends that load calculations for aircraft with less than seven seats should be based on the actual weight of occupants and baggage rather than standard or average weights.

Using actual weights for the load calculations would have prevented it operating with its centre of gravity aft of its rear limit.

“Using actual weights for the load calculations of the Sling 4 would have prevented it operating with its centre of gravity aft of its rear limit,” Mr Nagy said. “Operating like this meant it was less stable and more susceptible to an aerodynamic stall and harder to recover if a stall occurred.”

While descending, the Sling 4 deviated from its desired flight path. Attempts to continue the approach by manoeuvring the aircraft at low level and speed coupled with its loading outside of the permissible centre of gravity range reduced the remaining margins of controllable flight. 

The aircraft stalled and entered an incipient spin. Recovery from the stall was not possible and the aircraft collided with terrain. The fuselage fractured at the engine firewall and the engine was pushed rearward into the cabin. The aircraft was destroyed. The pilot and three passengers suffered serious injuries.

Further information: Guidance on the use of standard passenger and baggage weights for the calculation of aircraft weight and balance is available in the Civil Aviation Safety Authority’s advisory publication CAAP 235-1(1) Standard passenger and baggage weights(Opens in a new tab/window). Pilots can also refer to the United States Federal Aviation Administration publication Pilot’s Handbook of Aeronautical Knowledge Chapter ten, Weight and Balance(Opens in a new tab/window) for advice on correctly calculating aircraft weight and balance.

Read the final report: Collision with terrain involving The Airplane Factory Sling 4, VH-BEG, Caloundra Aerodrome, Queensland, on 12 August 2017

The ATSB’s investigation into the fuel exhaustion and forced landing of a Piper PA-28, registered VH-BDB (BDB), near Bankstown Airport, New South Wales, highlights the need for effective fuel management to avoid fuel starvation.

The accident occurred on 19 September 2017, when despite having enough fuel on board, the Piper aircraft had a loss of engine power that resulted in a forced landing, 15 km west-south-west of the airport. The loss of engine power was found to be the result of fuel starvation from the selection of a fuel tank with insufficient fuel to complete the flight.

ATSB Executive Director Transport Safety Nat Nagy says that accidents involving fuel mismanagement are an ongoing aviation safety concern.

“Each year, we receive more than 20 reports of fuel exhaustion or starvation,” Mr Nagy said.

You need to understand how the fuel system works on your aircraft, know how much fuel you have in each tank, and make sure you have the appropriate tank selected at all times.

In this occurrence, the pilot of BDB conducted a pre-flight inspection and believed the aircraft had full fuel on board and as the flight was only for 30-40 minutes did not intend to change the fuel tank selector during the flight.

As the aircraft returned to Bankstown and approached waypoint 2RN, the pilot noticed the engine was fluctuating. The pilot selected the electric fuel pump on, but the engine fluctuations became worse. The pilot then performed the engine failure immediate checks, but failed to change fuel tanks, and then carried out a forced landing. The pilot received minor injuries. The aircraft was substantially damaged.

Fuel exhaustion and starvation can occur during any phase of flight.  ATSB data shows that most reported occurrences have been in the cruise or in the descent, approach and landing phases of flight.

“You need to understand how the fuel system works on your aircraft, know how much fuel you have in each tank, and make sure you have the appropriate tank selected at all times,” Mr Nagy said. ‘To reduce the risk of a fuel starvation event when on descent, selecting the appropriate fuel tank during the pre-descent checks will avoid having to manage this during the higher workload period during approach to land.”

For information and procedures to avoid fuel starvation or exhaustion are available in the ATSB’s booklet Avoidable Accidents No.5 – Starved and exhausted: Fuel Management and aviation accidents(Opens in a new tab/window) as well as the Civil Aviation Safety Authority’s Civil Aviation Advisory Publication 234-1: Guidelines for aircraft fuel requirements.(Opens in a new tab/window)

Read the final report: Fuel starvation and forced landing involving Piper PA-28, VH-BDB, 15 km west-south-west of Bankstown Airport, New South Wales, on 19 September 2017

At 47 minutes past midnight, on 15 July 2017, the Spirit of Queensland tilt train was passing through Rockhampton on its way to Brisbane. Its route would take it through the intersection of Denison and William Streets, over a level crossing. The level crossing was a passive-type, with no active devices such as bells or flashing lights. Instead, there were posted signs alerting road drivers to the existence of the level crossing and the need to take care.

Five years earlier, a train had collided with a road vehicle at that intersection, and Queensland Rail and the Rockhampton Region Council had taken steps to resolve some minor issues with the sighting distance and signage.

Now, as the Spirit of Queensland approached the intersection, both of the train’s drivers identified that the intersection and its approaches were clear.

When the train crossed the intersection, however, they both heard a loud bang and there was jolt to the power car. The operating driver immediately applied the brakes and the train stopped about 40 metres later.

Upon alighting from the train, the driver found that the train had struck a road vehicle, a white Toyota Camry carrying four people inside. The car had driven in front of the train, and had been immediately struck on the driver’s side, causing it to spin and collide with the right-hand side of the train in the direction of travel.

Railway level crossing accidents have the potential to be catastrophic.

The three passengers of the car were treated for non-life-threatening injuries. The driver of the car and both train drivers were tested for alcohol and drugs. All tests returned zero readings.

Queensland Rail’s subsequent assessment of the site revealed no issues with sighting distance, signage, or design of the crossing.

According to the driver of the car, the car’s windows were open at the time of the incident, however, its occupants were actively engaged in conversation and none of them heard the train’s horn. The driver stated that the vehicle was slowed almost to a stop as it approached the intersection before accelerating to cross it. Neither the driver nor the passengers had noticed the train until immediately before the collision.

This incident is a reminder that all road vehicle drivers using railway level crossings equipped with passive controls need to be vigilant, observe road-warning signs, obey road rules and look out for trains.

ATSB Executive Director of Transport Safety Mr Nat Nagy said this was part of a familiar pattern in transport safety.

“Unfortunately, the ATSB has investigated a number of similar occurrences,” Mr Nagy said. “Last year alone, we initiated four investigations relating to level crossings. Thankfully, no one was killed this time, but that is not always the case.

“Railway level crossing accidents have the potential to be catastrophic. Taking the time to check and ensure that it’s absolutely safe to cross can make all the difference.”

Read the final report: Level crossing collision between Spirit of Queensland and a road vehicle, at Rockhampton, Queensland, on 15 July 2017

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.