The pilot of a Yakovlev YAK 9 warbird which entered a low altitude spin before impacting the ground had not previously conducted aerobatics in the aircraft and so was unlikely to be aware of its unique handling characteristics, an ATSB investigation into the accident has found.

The investigation report details that the pilot, prior to undertaking a planned instructional flight with an instructor in the YAK 9* later that afternoon, took off from Latrobe Regional Airport, Victoria shortly after 2:20pm on 7 September 2018 for a local private flight.

Data from the nearby East Sale RAAF Base air traffic control radar showed the aircraft tracked first to the south-west, maintaining runway heading, before turning north-west. North of the town of Moe, at an altitude of about 2,800 feet above sea level, the pilot began to conduct what witnesses on the ground described as aerobatic manoeuvers.

The pilot was endorsed for aerobatic manoeuvres completed by 3,000 feet above ground level but had not previously conducted aerobatics in the YAK 9.

With limited experience and recency in flying the YAK 9, the pilot was likely unaware of the aircraft’s unique handling characteristics during aerobatic manoeuvres or spin recovery.

One witness described observing the aircraft perform what appeared to be a roll followed by a loop. The aircraft came out of the bottom of the loop and made an abrupt left turn before spiralling towards the ground. Video taken by another witness showed the aircraft in a spinning, steep nose‑down attitude prior to disappearing from view.

The aircraft was found to have impacted the ground in a paddock about 3 km north of Moe, in a flat, slightly right‑wing and nose-low attitude consistent with an aircraft established in, or recovering from, a spin. The pilot was fatally injured and the aircraft destroyed.

ATSB Transport Safety Director Stuart Macleod said the accident highlights the risks inherent with performing low-level aerobatics in high performance aircraft.

“High‑performance aircraft like the YAK 9 transition into a fully developed spin quicker and more forcefully than a typical light training aircraft. It is essential to have sufficient altitude to effectively recover from a spin,” he said.

“Experienced YAK 9 pilots stated that, depending on pilot experience, 5,000 to 7,000 feet is required to safely recover the aircraft from a developed spin.

The report notes, unlike in most other warbird aircraft, as the airspeed increases during a high-speed dive recovery, in the YAK 9 the effort required to pull back on the control stick reduces. 

“This investigation reinforces to pilots performing low-level aerobatics the importance of observing minimum approved operating heights, commensurate with their ability and qualifications, and to engage in regular flight reviews and instruction.”  

The investigation report notes the pilot had conducted aerobatics in a number of warbird aircraft but only had between five and six hours of flying experience in the YAK 9, and that the accident flight was the pilot’s first in the aircraft in three months.

“With limited experience and recency in flying the YAK 9, the pilot was likely unaware of the aircraft’s unique handling characteristics during aerobatic manoeuvres or spin recovery,” Mr Macleod said.  

The ATSB investigation also identified a number of safety issues that while they did not directly contribute to the accident flight, increased risk.

For example, the aircraft’s canopy had been opened intentionally in flight the previous day, resulting in the loss of documentation from the aircraft including the aircraft checklist, flight manual and maintenance release.

“Pilots need to ensure that careful preparation and planning is undertaken prior to each flight and that all documentation, checklists and required manuals are appropriately stored and accessible within the aircraft,” Mr Macleod said.

In addition, post-accident examination of the aircraft identified incomplete maintenance practices, including inadequate airframe anti‑corrosion measures and insecure primary flight controls and seat fasteners.

* The YAK-9 was a Russian-designed single-seat fighter aircraft used during the Second World War, similar in performance to the Spitfire and P-51 Mustang. The accident aircraft, a YAK-9 UM, was a replica of the original design, built in the 1990s and fitted with two seats and an American-built, rather than Russian, engine.
 

Read the final report: Loss of control and collision with terrain involving YAK-9UM, VH-YIX, 19 km west-north-west of Latrobe Regional Airport, Victoria, on 7 September 2018

The derailment of two freight wagons and the subsequent disruption to freight and passenger services has highlighted the importance of inspection techniques that effectively monitor and report on asset condition.

On 7 June 2019, Pacific National freight train 6CM3 was operating between Griffith, in New South Wales’ Riverina region and Melbourne’s Appleton Dock. A roll-by inspection from the Down platform at Junee station detected that the 40th and 41st wagons of the train had derailed.

The investigation, conducted on behalf of the ATSB by NSW’s Office of Transport Safety Investigation (OTSI), found that the wagons had derailed at a broken rail about 300 metres before the platform. The rail had broken in two places, allowing the wagons’ wheels to derail, damaging the wagons and infrastructure.

The investigation found that, following a change in maintenance practices, rails forming turnouts between main lines were not being ultrasonically tested. As a consequence, a likely detectable rail defect went undetected, with the two rail breaks occurring at different times.

The crew’s detection of the derailed wagons prevented an escalation of the occurrence.

As a result of the incident, the Australian Rail Track Corporation identified rails forming turnouts that were not previously subjected to ultrasonic testing. Those rails were included in the asset management register, and testing was scheduled.

The investigation’s safety message highlights that managers of rail infrastructure should ensure that inspection techniques effectively monitor and report on asset condition.

Further, risk controls should be continuously assessed through the life cycle of the asset, in particular when changes are made to inspection regimes.

Read the final report: Derailment of freight train 6CM3, Junee, New South Wales, on 7 June 2019

The derailment of a freight train near Kalgoorlie in Western Australia highlights the need for train crews to consistently apply procedures to reduce train speed in anticipation of a stop indication at train order locations, a new ATSB reports says.

A senior driver and trainee driver were crewing Pacific National train 7MP7 as it travelled from Cook, South Australia, to Parkeston near Kalgoorlie in Western Australia on 19 August 2018 when it approached the points located at the eastern end of the Coonana train order location. Around four hours earlier, the trackside interlocking at Coonana had detected that the point machine at the eastern end had not set correctly for the main line following the passage of a previous train. The colour light indicator (enhancer) situated adjacent to the point machine displayed a red light (stop indication) to the approaching train crew of 7MP7.

During the approach to Coonana, the train crew of 7MP7 maintained track speed while looking for the light displayed by the enhancer ahead. When they realised that they could not see the enhancer, they braked but were unable to stop the train before it traversed the eastern point machine travelling at 44 km/h and derailed. The two lead locomotives, unoccupied crew car and first two platforms of the lead wagon derailed, destroying around 200 metres of the main and crossing loop tracks. The train crew were uninjured.

ATSB Director Transport Safety Dr Stuart Godley said the ATSB’s investigation into the derailment highlights the practice of maintaining momentum approaching a train order location, before confirming the enhancer indication.

The variability in the distance for the effective sighting of enhancers and targets at safety critical locations means the available distance when an indication is sighted may be less than the effective braking distance of the train.

“The variability in the distance for the effective sighting of enhancers and targets at these safety critical locations means the available distance when an indication is sighted may be less than the effective braking distance of the train if the train is still maintaining track speed, which represents a limitation in the system,” Dr Godley said.

“This limitation places the onus on train crews to implement a rule-based procedure to reduce speed at defined locations repeatedly, in preparation for an anomalous event where the enhancer might display a red stop indication.”

The investigation found that a breakdown in verbal communication between the supervising driver and trainee driver controlling the locomotive likely resulted in a misunderstanding of the significance of not sighting the light enhancer, and the urgency of the intended action to brake the train.

“The manipulation of locomotive control inputs in response to the situation highlighted how the on-the-job component of the Pacific National driver competency program did not adequately prepare the trainee driver to control the train in response to an emergency.” Dr Godley said.

Consequently, train 7MP7 approached the eastern end of Coonana at a speed where it was unable to stop before the open points

The investigation also determined that an incorrectly stored lock pin from a point clamp at the Coonana train order location had fouled the indicator’s throw arm pivot mechanism, preventing the correct movement of the points to reset for the main line after the departure of the previous train. 

Since the incident Australian Rail Track Corporation removed all the point clamps and relocated them to the adjacent equipment huts at locations between Malbooma and Parkeson as well as replacing all incandescent type indicators with long-range LED luminaire type indicator units to improve conspicuity of the indication.

Separately, Pacific National have also introduced a signal passed at danger (SPAD) reduction program and reinforced with train crews the need to reduce speed in preparation for stopping short of facing points, until both drivers confirm recognition and understanding of indicator aspects.

Read the final report: Derailment of train 7MP7, at Coonana, Western Australia, on 19 August 2018

A separation incident occurred when an Airbus A320 airliner and an Aero Commander 500 piston twin light aircraft were on converging flight paths when operating to and from reciprocal runways at Sunshine Coast Airport, an ATSB investigation details.

The incident occurred at about 6:35am on 4 November 2019, outside the operating hours of the airport’s air traffic control tower, and so Class G (uncontrolled) airspace procedures were in place with the pilots using radio broadcasts on the common terminal advisory frequency (CTAF*) to ensure sequencing and mutual separation with other aircraft. The A320 was on approach to land on runway 18 while the Aero Commander was departing from the reciprocal runway, runway 36.

“The ATSB found that the A320 flight crew and the Aero Commander pilot did not hear important CTAF radio broadcasts made regarding each other’s position and intention,” said ATSB Executive Director Transport Safety Nat Nagy.

“These included the inbound broadcasts made by the A320 and the take-off broadcast made by the Aero Commander.”

Mr Nagy noted the Aero Commander pilot likely had yet to turn the radio on at the time the A320 flight crew made their inbound radio broadcasts. The A320 flight crew, meanwhile, did not hear the rolling for take-off broadcast made by the Aero Commander pilot, which occurred at the same time as Brisbane Centre was contacting the A320 on the Brisbane Centre frequency. (Brisbane Centre was providing a traffic information service.)

When operating in uncontrolled airspace to and from non-towered aerodromes, it is important that pilots ensure that the location and intention of surrounding traffic is well understood and communicated prior to commencing take-off or landing.

The two aircraft established direct communications with each other when the A320 first officer broadcast on the CTAF that they were turning on a five (nautical) mile final approach for runway 18 and asked if the Aero Commander pilot was holding short of the runway. The Aero Commander pilot responded as being airborne, that the A320 was in sight, and the intention to track to the A320’s left (by making a right turn).

The aircraft passed each other with a recorded separation of 0.7 nautical miles horizontally and 265 feet vertically. The A320 landed at Sunshine Coast Airport and the Aero Commander continued to Maryborough without further incident.

The ATSB investigation noted that the A320 flight crew elected to use runway 18 for landing after listening to the aerodrome weather information service radio broadcast. However, this was either incorrectly recorded or they misheard the wind conditions, as runway 36 was instead the more suitable runway based on the actual wind at the airport. This resulted in the A320 approaching the opposite runway to that being used by other aircraft at the time.

The investigation also found that the Aero Commander pilot did not confirm the location and intention of the inbound A320 prior to commencing take-off, on the assumption that the A320 would use the most suitable runway for the wind conditions.  

“This investigation highlights that when operating in uncontrolled airspace to and from non-towered aerodromes, it is important that pilots ensure that the location and intention of surrounding traffic is well understood and communicated prior to commencing take-off or landing,” Mr Nagy said.

 A number of resources are available to pilots operating in non-controlled airspace including the ATSB publication A pilot’s guide to staying safe in the vicinity of non-controlled aerodromes and the Civil Aviation Safety Authority(Opens in a new tab/window)’s ‘be heard, be seen, be safe(Opens in a new tab/window)’ resource booklet, Mr Nagy noted.

* Pilots operating at non-towered aerodromes are expected to make a series of standard broadcasts on the CTAF regarding their position and intentions. Broadcasting on the CTAF reduces the risk of a mid-air collision or reduced separation by supporting pilots’ visual lookout for traffic and situational awareness, and assists them to mutually separate their aircraft. This is known as radio-alerted ‘see-and-avoid’.

Read the final report: Separation issue involving Airbus A320, VH-VQG, and Aero Commander 500, VH-UJS, near Sunshine Coast Airport, Queensland, on 4 November 2019

A newly-replaced points machine at Brisbane’s Eagle Junction station resulted in a signal displaying an incorrect authority to proceed to a suburban passenger train as it had been pre-wired in accordance with an outdated master circuit diagram.

The incident occurred on 23 September 2018 when signal EJ45 displayed an invalid authority for the positioning of the points ahead for passenger train DP41, which was about to depart the station. Both the driver and a signal electrician noticed the irregularity and reported it to the network control officer, who directed the driver to remain at the platform. A short time later, another train approached and crossed over the conflicting route.

“The actions of the driver, the network control officer and the signal electrician in identifying the irregularity and stopping the train departing Eagle Junction mitigated the potential for a collision,” noted ATSB Director Transport Safety, Dr Stuart Godley.

An ATSB investigation found that the new points machine was pre-wired in accordance with the master circuit diagram. However, it was likely that the master circuit diagram was not updated to reflect modifications made to the old points machine to accommodate the Airport Line (which opened in 2001 and branches off the Queensland Rail City network at Eagle Junction).

Accurate and up-to-date engineering documents correlating with in‑field equipment are fundamental to the effectiveness of an engineered interlocked signalling system to maintain train separation.

“This introduced an inadvertent wiring error, resulting in the signal interlocking systems indicating the points were set in the normal position, whether they were or not,” Dr Godley said.

“Accurate and up-to-date engineering documents correlating with in‑field equipment are fundamental to the effectiveness of an engineered interlocked signalling system to maintain train separation.”

Queensland Rail have since introduced a procedure requiring correlation between the in-field signalling equipment and the master circuit diagrams before safety critical work is undertaken, Dr Godley noted.

Read the final report: Signalling irregularity involving train DP41, Eagle Junction, Queensland, on 23 September 2018

The fatal injuries sustained by a container ship crew member who became trapped between an elevator cage and a bulkhead highlights the importance of applying existing safety management procedures, an ATSB investigation notes.

The 3 June 2018 accident occurred when the electro-technical officer (ETO) of the OOCL Kuala Lumpur, which was preparing to enter Port Botany, Sydney, was testing the ship’s personnel elevator after completing mechanical repairs. While driving the elevator from the cage top, the ETO became trapped between the moving cage and the bulkhead, sustaining fatal injuries.  

The ATSB investigation found that the ETO was last seen alone, on top of the elevator cage, in the prescribed safe zone with the elevator control in ‘MANUAL’. The exact circumstances as to how and why the ETO then came to be trapped while the elevator moved between floors could not be determined.

More than 10 fatal ship elevator accidents have been reported internationally since 2007.

However, for the accident to have occurred, the ETO had to have moved from the safe zone, the elevator control had to have been changed from ‘MANUAL’ to ‘AUTO’ and the elevator called.

The investigation also found that safety barriers prescribed in the electrical work permit were not put in place before the elevator maintenance work commenced. This included that there had been no warning announcement, and, consequently, all of the ship’s crew had not been warned against using the elevator. In addition to this, there were no warning signs posted at all elevator access doors.

This allowed an elevator call to be made while the work was underway.

“Elevator accidents continue to occur around the world and result in about one fatality per year,” said ATSB Director Transport Safety Stuart Macleod.

“Many of these accidents involve the failure to apply existing safety management procedures and/or identified safety barriers that have proven effective in reducing the risks associated with elevator maintenance.”

Further, the injured person was often working alone and riding the elevator cage, Mr Macleod noted.

“For any task that is performed on multiple occasions without any adverse consequence, there is the potential for an individual’s perception of risk, or expectancy of a problem, to decrease,” Mr Macleod said.

“This makes it all the more important to always follow documented procedures and safe working practices, even when the operation is considered safe.”

This accident also highlights that it is imperative that close and careful supervision is maintained for any elevator testing and tasks.

“Supervisory oversight provides an opportunity for experienced, senior technical staff to scrutinise and assess the plans and intentions of those completing the task. This provides an external check and safety barrier before, and during, the work.”

Read the final report: Fatality in the elevator trunk on board OOCL Kuala Lumpur, 8.5 nautical miles south-east of Port Botany, New South Wales, on 3 June 2018

A data input error contributed to the flight crew of an Airbus A320 turning left shortly after take-off contrary to the cleared standard instrument departure, and at a height of about 223 feet above the ground, below the minimum height for turns specified by the operator, an ATSB investigation has found.

The Indonesia AirAsia A320, with six crew and 145 passengers on board, was operating a scheduled passenger service from Perth to Denpasar, Bali on 24 November 2017.

The subsequent ATSB investigation found that the first officer, who was the pilot flying, had assumed runway 03 would be in use, and not the reciprocal runway 21. On the previous sector into Perth, the aircraft had landed on runway 03, and the first officer believed that they would be using the same runway for take-off, as he had done on previous occasions.

Consequently, the first officer programmed runway 03 for take-off into the aircraft’s flight management guidance system (FMGS) before listening to the automatic terminal information service (ATIS) broadcast for Perth Airport, which detailed that runway 21 was in use.  

Although the first officer noted runway 21 on his paper flight plan, he did not notice this differed from what he had programmed into the FMGS, and he briefed the captain for a runway 03 take-off.

Further, the captain, who was pilot monitoring, did not independently verify the runway in-use during his pre-departure checks, and likely relied on verbal information from the first officer, the investigation report details.

Despite a number of cues available, including several air traffic control (ATC) instructions for using runway 21 and airport signage, and later reporting to the ATSB feelings of unease about the flight preparations, the flight crew did not detect the incorrect programming of the FMGS.

Due to that incorrect programming, shortly after take-off from runway 21, the flight director on the aircraft’s primary flight displays commanded a left turn. When at about 223 feet above ground level, the first officer initiated the turn and then engaged the autopilot, which started the left turn to navigate the aircraft towards the first programmed waypoint, which was in-line with the opposite runway direction and behind the aircraft.

ATC quickly noticed the diversion from the cleared track and corrected the crew’s heading.

Later in the climb, once the crew had detected that the FMGS had been incorrectly programmed, the captain reprogrammed the correct flight plan in the FMGS, rather than selecting the heading assigned by ATC. This resulted in the aircraft turning through the ATC-assigned heading, requiring further instructions from ATC, before the flight continued on to Denpasar without further incident.

“Deviating from standard procedures, even slightly, can render them ineffective and result in errors,” said ATSB Director Transport Safety Dr Stuart Godley.

“The incident highlights the significance of stopping and re-evaluating the situation while on the ground when there is a feeling of uncertainty about the flight, even if it results in undesirable delays. This provides an opportunity to detect errors before they affect operations, as, once airborne, workload and time limitations become even more critical due to the rapidly changing situation.”

Since the incident, Indonesia AirAsia have incorporated a ‘change of departure runway’ scenario in their line operations flight training. The airline also has plans to launch a cross-departmental initiative to increase the awareness and skill sets of pilots, especially in the area of threat and error management.

Data input errors are one of the ATSB’s SafetyWatch priorities.

Read the final report: Data entry error and operational non-compliance involving Airbus A320, PK-AZE, Perth Airport, Western Australia, on 24 November 2017

A Eurocopter EC130 helicopter was substantially damaged when on take-off it yawed to the left greater than the pilot was expecting, then rolled and impacted the ground after the left skid contacted a raised mound.

The helicopter was departing a private property near Mansfield, Victoria, on its return to Melbourne’s Moorabbin Airport on 19 January 2019 with a pilot and two passengers on board.

The pilot would later recall to ATSB investigators that he lifted off the helicopter more rapidly than he normally would, without first letting the helicopter ‘rest’ lightly on the skids and applying control inputs to lift it gently into a balanced, controlled hover for the climb out.

“The higher-than-normal application of control inputs resulted in the torque from the main rotor not being balanced by the anti-torque from the Fenestron tail rotor,” said ATSB Director Transport Safety Stuart Macleod.

“Consequently, once the helicopter was off the ground it yawed significantly to the left.”

The ATSB’s investigation report notes that the EC130 is equipped with a shrouded ‘Fenestron’ tail rotor, which requires greater right pedal input to overcome torque from the main rotor during lift-off compared to a helicopter with a conventional tail rotor. The pedal control inputs are also not linear with respect to the effect on helicopter yaw.

This accident demonstrates how critical it is that pilots understand their aircraft’s characteristics so that they can anticipate its response when becoming airborne, and are not surprised by how it handles.

Mr Macleod noted the pilot reported that for the accident flight he principally applied cyclic control rather than the required full application and maintenance of opposing right, tail rotor pedal input. When these inputs did not arrest the yaw rate, the pilot assessed that the best option was to land the helicopter.

“This accident demonstrates how critical it is that pilots understand their aircraft’s characteristics so that they can anticipate its response when becoming airborne, and are not surprised by how it handles,” Mr Macleod said.

“The rapid development of the accident sequence - about five seconds - also illustrates the limited time for pilot actions and decisions in such hazardous situations, which fortunately did not result in serious injury in this case.”

In July 2019, about six months after the accident, Airbus Helicopters published a safety information notice(Opens in a new tab/window) to highlight the potential for unanticipated and rapid left yaw in helicopters with clockwise rotating main rotors. It further noted that even if the pilot’s response was prompt, the yaw might not immediately subside, and lead to the pilot thinking that the input was ineffective.

Read the final report: Loss of control and collision with terrain involving EC130 helicopter, VH-YHS, 19 km south-south-east of Mansfield, Victoria, on 19 January 2019

Poor track condition including a short twist defect as well as a higher than specified train speed contributed to the derailment of 11 loaded grain wagons south of Narwonah, north-western New South Wales, on 1 October 2017.

The Pacific National grain train service 8838N, comprising two 81-class locomotives and 23 wagons, was travelling from Nevertire to Manildra on the Australian Rail Track Corporation (ARTC) operated rail network, when the 11 grain wagons located at the rear of the consist derailed. An emergency brake application occurred in response to the uncoupling, which brought the front portion of the train to a stop. There were no injuries but there was substantial damage to nine wagons and track infrastructure. 

A transport safety investigation into the derailment, conducted on behalf of the ATSB by NSW’s Office of Transport Safety Investigation (OTSI), found that maintenance of previously identified track defects near the derailment site was not successful in preventing the defects from re-occurring. The investigation also established that the train crew, comprising a driver and an assistant driver, were operating the train at a speed of approximately 80 km/h, in excess of the 60 km/h limit for that section of track specified by ARTC.

This incident highlights the importance of ensuring that track is free from any defects, and that trains travel at or below the speed specified in the standards.

“The incident highlights the importance of ensuring that track is free of defects that effect safety and that trains travel at or below the speed specified in rail network standards,” said OTSI Chief Executive Office Mick Quinn.

The defects around a rail joint and the train speed contributed to the vertical unloading of the wheels on the 12th wagon, Mr Quinn noted.

 “Train 8838N was travelling at 82 km/h immediately before the derailment, where the specified speed for its axle loading was 60 km/h. It is likely that this increased the risk of derailment,” Mr Quinn said. “Also, if other wagons had travelled frequently over this track at increased speeds, this may have led to a more rapid deterioration of the track.”

Repairing the damaged section of track required the replacement 300 m of rail, fasteners and sleepers and 150 m of new formation.

Since the derailment ARTC made a number of changes to its track maintenance systems and processes, and is continuing with steel and concrete re-sleepering and rail joint removal programs to its network in central and north-western NSW.

Read the final report: Derailment of grain train 8838N, Narwonah, New South Wales, on 1 October 2017