Risks are not confined to the road vehicle and occupants – there is also a high likelihood of train derailment after any track collision, with significant associated risks to the train crew, passengers, freight and infrastructure.

On 12 October 2014, Train 7MD3 (comprising two locomotives, crew car and 78 wagons loaded with manganese ore) struck a utility road vehicle, at a speed of about 70 km/h, on a track near the Katherine River Bridge in the Northern Territory.

While the road vehicle became lodged under the lead bogie, the locomotive and the trailing wagons remained on track. The train travelled approximately 500 m further before finally coming to rest atop a culvert bridge, with the damaged vehicle hanging precariously over the right side of the bridge.

This occurrence highlights the very significant risk of injury, death and serious damage that is associated with road vehicle operators attempting to cross railway tracks in areas other than designated level crossings.

The co-driver contacted Train Control and reported the collision while the driver went to the crew car to ensure the wellbeing of the other train crew before all three returned to the lead locomotive. One of the crew inspected the road vehicle and ascertained that no one was trapped inside.

Northern Territory Police officers attended the scene and provided assistance to all four crew members. Neither the driver of the vehicle nor any of the train crew was injured in the collision, although one member of the train crew was taken to hospital as a precautionary measure. All crew members were relieved from duty. The driver of the vehicle was interviewed by the Northern Territory Police. During the interview, the driver informed the interviewing officers that he had been attempting to traverse the track just west of town when his car became stuck. Upon realising the approach of a train he had attempted to warn the train by flashing a torch.

Read the final report: Train 7MD3 collision with motor vehicle, Katherine, Northern Territory, on 12 October 2014

On 17 February 2013, ore train 9614S was departing Spencer Junction en route to Whyalla, South Australia. While the train was traversing 38A points at the northern end of Spencer Junction, the driver noticed a change in the train’s dynamic behaviour and immediately reduced the throttle.

The train then quickly came to a stop due to the automatic application of the electronically controlled pneumatic train brake. Upon inspection of the train, the second driver discovered five ore wagons were derailed.

The ARTC’s inspection and maintenance practices were ineffective at identifying and correcting the deteriorating condition of track infrastructure exhibiting accelerated wear, such as 38A points at Spencer Junction.

The ATSB’s investigation found that the leading edge of the right hand 38A point blade was worn and damaged. The blade damage had created a ramping angle, allowing the lead wheel of the ore wagon to “ride up” the blade and derail. The derailed wheels then impacted and damaged the concrete sleepers, which ultimately failed to maintain track gauge and allowed further wagons to derail. During the derailment sequence, a rupture to the train’s electronic control pneumatic pipe initiated the application of the train brake.

The ATSB found that the Australian Rail Track Corporation’s inspection and maintenance regime, following two similar derailments at the same location, had not been sufficient to identify and remediate the deteriorating condition of the 38A points, and ultimately contributed to the derailment.

In the months leading up to this derailment, Genesee Wyoming Australia (GWA) and the Australian Rail Track Corporation (ARTC) had agreed to a rail upgrade programme which included a new turnout incorporating 38A points, using 60 kg rail laid on concrete bearers. At the time of this derailment, a new turnout had been prepared, but had not yet been installed. Upgrade works have since been completed.

Following installation of the upgraded infrastructure, more frequent monitoring for wear rates of the point blade(s) was undertaken. After several months of condition monitoring it became evident that track performance and wear rates could be managed as specified in the Code of Practice and the normal inspection schedule was reinstated.

Safety message

Track infrastructure owners and maintainers should consider the associated increase in wear on track infrastructure when there is an increase in the volume of rail vehicles being operated. The high dynamic forces that may be exerted from rail vehicles, specifically those that bear a heavy axle load, will accelerate the rate of wear on track infrastructure.

In these circumstances, increased inspection and maintenance of track components should be considered until it can be established that resulting wear rates can be adequately managed in accordance with the established standards.

Read the final report: Derailment of train 9614S, near Port Augusta, South Australia, on 17 February 2013

The Pacific National broad-gauge freight train, No. 9204V, was travelling from Warrnambool to Appleton Dock, Victoria. Due to track works at West Footscray Junction—to repair damage arising from a previous derailment—the train was despatched from Tottenham Yard toward the port via an alternative route, the adjacent dual-gauge Main line.

Track circuit failures resulting from the track damage meant that Up-direction Home signals on the Main line were displaying Stop indications, and for this reason the train had departed Tottenham yard on the authority of a Signalman’s Caution Order. The locomotive crew received two further Caution Orders en-route, the last of these being for Home signal DYN158.

Signal DYN158 protected a turnout that provided for a diverge of the standard-gauge line away from the broad-gauge, and the network control officer (NCO) had inadvertently set this turnout for a standard-gauge movement. The locomotive crew proceeded past the Home signal and through the points, resulting in derailment of the locomotive and one wagon at low speed.

The ATSB has recommended that ARTC undertakes further action to address the risk of directing trains onto incorrect gauge track in dual-gauge territory.

The ATSB found that the NCO had established a standard-gauge route beyond signal DYN158 rather than the required broad-gauge route. Although the Train Control System software incorporated an on-screen gauge alarm to warn an NCO against setting an unviable route, in this instance that screen alert did not appear, since its generation was contingent on the gauge detection system that was not functioning. The signalling system had been degraded as a result of a previous derailment.

The Train Control System permitted the NCO to establish a route on an incorrect gauge for train 9204 and displayed that route as viable.

ARTC has introduced provisions to ensure that modifications made to the Phoenix Train Control System display are fully understood by Control Centre staff, and has also modified the Signalman’s Caution Order form to provide explicitly for the checking of the intended route and for the train crew to check the setting of points to be traversed.

The ATSB has recommended that ARTC undertakes further action to address the risk of directing trains onto incorrect gauge track in dual-gauge territory.

Safety message

When the signalling system and the functionality of safety intervention devices is degraded and an alternative process of safeworking is in use, there is a need for a heightened level of awareness and caution on the part of network control officers and train crew.

When designing control system safety mechanisms, such as the Gauge Alarm in this instance, the rail operator should consider all possible sub-system failures to ensure the intervention remains effective under all circumstances.

Read the final report: Derailment of freight train 9204V, Sims Street Junction, West Melbourne, Victoria, on 4 December 2013

Flying at night in remote areas without sufficient visual cues continues to be one of the most dangerous forms of flying, as evidenced by a recent fatal accident in Western Australia’s Kimberley region.

An ATSB investigation into the accident found the pilot of an R22 helicopter, who did not hold a night visual flight rules (VFR) rating or instrument rating, continued flying after last light to try to reach Springvale station.

The lack of local ground lighting on a moonless night meant the pilot had no visual cues to know exactly where the   helicopter was going or reliably control its attitude, and collided with terrain 46km short of the intended destination.

Night flying continues to pose a high risk for many pilots, particularly those in remote areas where there is little to no ground lighting. On average there are two accidents a year that occur from visual flight at night.

“We continue to be concerned about the frequency of accidents – many fatal – that involve pilots flying with reduced visual cues,” said ATSB Chief Commissioner Martin Dolan.

“Based on research from other countries, accidents at night tend to be unforgiving and more likely to lead to death.”

In the 20 years between 1993 and 2012 there were 26 accidents in Australia that occurred in visual (night) conditions. There were also another 10 accidents involving inadvertent VFR flight into 'instrument meteorological conditions', such as poor weather or cloud. Those 36 accidents resulted in 58 deaths. Nearly all of the accidents occurred on dark nights.

“This fatal accident in the Kimberley highlights the inherent high risk of night flying in remote areas,” Mr Dolan said.

For pilots, the ATSB’s message is simple.

“Day VFR pilots need to plan to arrive at their destination at least 10 minutes before last light and to have a realistic ‘Plan B’ to use when it becomes apparent that an intended flight cannot be completed in daylight,” Mr Dolan said.

“It is important, also, for operators and others involved in the operation of aircraft to actively support safety-first pilot decision-making.”

An important safety message

Flying with reduced visual cues is one of the ATSB’s nine SafetyWatch priorities.

Under visual flight rules (VFR), it is crucial pilots have sufficient visual reference to see and avoid obstacles. Visual cues are also required to maintain orientation so VFR pilots know which way is up and can maintain control of their aircraft. There are often less visual cues at night, even though visibility may be good.

More information on flying with reduced visual cues can be found at: www.atsb.gov.au/safetywatch

Read the final report: Collision with terrain involving Robinson R22 helicopter, VH-YPC, 70 km north-west of Halls Creek, Western Australia, on 25 August 2014

On 13 July 2014, the pilot of a Cessna 172 aircraft, registered VH-EEC, conducted a private flight from The Lily to Narrikup aeroplane landing areas (ALA), Western Australia, with two passengers on board.

At about 1320 Western Standard Time, the pilot broadcast an inbound call when about 10 NM north-east of Narrikup at about 6,500 ft above mean sea level (AMSL). The pilot elected to conduct an approach to runway 06 and overflew the runway at about 1,900 ft AMSL. He observed the windsock which did not indicate any significant crosswind. The aircraft then descended to circuit height and joined on the crosswind leg for runway 06.

When established on final for runway 06, the pilot reported that he had selected two stages of flap and had the aircraft stabilised at about 65 kt. When about 50 ft above ground level, the pilot reported that the aircraft encountered a wind gust which carried the aircraft about 30 m to the right. The pilot moved the aileron controls into wind and applied full power to commence a go-around; however, the aircraft’s right wing collided with trees on the right side of the landing area. The pilot reported that the right wing may have stalled as he applied full right aileron. The aircraft fell to the ground resulting in substantial damage.

This incident highlights the importance of being ready to conduct an early go-around when a pilot is not completely satisfied that a safe landing can be made.

A go-around, the procedure for discontinuing an approach to land, is a standard manoeuvre performed when a pilot is not completely satisfied that the requirements for a safe landing have been met. The need to conduct a go-around may occur at any point in the approach and landing phase, but according to the United States Federal Aviation Administration (FAA), the most critical go-around is one initiated when very close to the ground. Consequently, the sooner a condition that warrants a go-around is recognised, the safer the manoeuvre will be.

The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. One of the safety concerns is that general aviation pilots continue to be involved in accidents that are mostly avoidable. A range of procedures and requirements exist to enable pilots to manage the hazards associated with common avoidable accident types.

The following provide useful information on go-arounds:
• Aviation safety explained – Go-arounds(Opens in a new tab/window)
•

Read the final report: Collision with a tree involving a Cessna 172, VH-EEC, 19 km north-north-west of Albany, Western Australia, on 13 July 2014

On 8 March 2013, during climb after departure from Tyabb aerodrome, Victoria, the pilot and sole occupant of a Jabiru J430 aircraft, reported the onset of vibration through the airframe.

As a precaution, the pilot began to turn the aircraft back towards Tyabb. During the turn, the propeller separated from the aircraft, necessitating a forced landing upon tidal flats at the western edge of Westernport Bay. The pilot was not injured and was able to disembark the aircraft safely.

A potentially serious accident was avoided by the pilot’s adherence to emergency procedures and maintaining control of the aircraft after a significant mechanical failure.

The ATSB investigation found that most of the cap screws connecting the propeller mounting flange to the engine crankshaft had failed by bending fatigue fracture – principally due to repeated relative movement between the mounted components. This movement was traced to a combination of an ineffective, multi-step torqueing method and the relaxation of tension within the crank–flange joint due to the compression of multiple layers of paint within the joint. It was also found that there were some anomalies within the maintenance documentation that related to these areas.

After attempting to analyse the origin of the worsening vibration in the aircraft, the pilot correctly followed emergency procedures both before and after the propeller loss. The over-water return decision limited the risks associated with the forced landing, and the pilot effectively maintained control of the aircraft throughout the descent and landing.

In July 2011, the manufacturer had improved the strength and reliability of the crank–flange joint by adding positive-location dowels in all new-production engines. However, that modification was not extended to earlier design assemblies, which included VH-TJP. The current (revised) issue of the Engine Overhaul Manual has an added strong recommendation for inclusion of these dowels at the next full overhaul or at bulk strip of engines manufactured prior to July 2011. Furthermore, in addition to the earlier requirement for no paint on mating faces or where screw heads bear, a broad requirement was introduced to ensure that no paint, thread-locking compound or contaminants remain in the propeller flange joint. The fastener torqueing method has been amended to a single-step process in which the required torque is to be obtained dynamically while the fastener is being turned.

Finally, the manufacturer’s Propeller Flange Attachment Service Bulletin now refers maintainers directly to the engine overhaul manual for installation procedures – removing the variability that previously existed between documents.

A potentially serious accident was avoided by the pilot’s adherence to emergency procedures and maintaining control of the aircraft after a significant mechanical failure.

Regarding the mechanical assembly, the ATSB encourages manufacturers and maintainers to consider older and legacy operating assemblies when designs are optimised or improved to enhance safety and reliability.

Read the final report: Propeller loss involving Jabiru J430, VH-TJP, north of French Island, Victoria, on 8 March 2013

On 23 May 2014, at about 0810 EST, the crew of a Bell 412 helicopter, were tasked by the Queensland Emergency Medical System Coordination Centre (QCC) to conduct a rescue in the Mount Spec area about 72 km WNW of their base in Townsville, Queensland.

Due to the inaccessibility of the area by road and the reported condition of the patient, the crew planned to conduct a winching operation. The crew consisted of a pilot, an air crew officer (ACO), a rescue crew officer (RCO), a paramedic and a doctor.

The pilot established the helicopter in a hover about 100 ft above the ground facing down the slope. The ACO directed the pilot to manoeuvre the helicopter to perform the operation and remain clear of all obstacles. The doctor and RCO were winched down to the site together, and subsequently the paramedic was lowered. The pilot conducted an orbit before returning to winch the stretcher and rescue equipment down.

This incident highlights to helicopter pilots the importance maintaining a good reference point when operating in confined areas.

The pilot and ACO then departed and after about 15 minutes, returned to commence the winch recovery. The ACO directed the pilot to manoeuvre the helicopter and winched up the doctor and the stretcher. The ACO handed the visual reference over to the pilot, while his attention was focused on securing the stretcher inside the cabin.

About 1 minute later, the ACO returned to the door and observed that the helicopter had drifted back and left and he immediately directed the pilot to manoeuvre up and to the right, however the tail rotor collided with some foliage. The ACO advised the pilot. The pilot had not detected any strike, there were no abnormal indications or vibrations, and the helicopter was operating normally.

The RCO and paramedic were then winched into the helicopter and the ACO returned to the front seat. After landing, the pilot observed some ripples on the tail rotor blades. 

This incident highlights to helicopter pilots the importance maintaining a good reference point when operating in confined areas and to establish the helicopter into the safest position possible particularly while the other crew members’ attention is focused inside the cabin. It also provides a reminder to clarify understanding between crew members, as in this incident the ACO knew the tail rotor had struck foliage, and the pilot had thought it was the main rotor and based his decisions on that belief.

Read the final report: Collision with terrain involving a Bell 412, VH-ESD, 72 km west-north-west of Townsville, Queensland, on 23 May 2014

On 10 May 2014, an accredited Cirrus salesman conducted a sales demonstration flight of a Cirrus SR22 aircraft, registered N802DK, in the local training area, from Bankstown Airport, New South Wales, with a pilot (and potential aircraft buyer) seated in the front left seat and one passenger on board.

At about 1330 Eastern Standard Time, the aircraft departed Bankstown and the salesman, as pilot in command (PIC) elected to track towards Katoomba at about 6,000 ft above mean sea level.

This incident provides a reminder to pilots to know your own limitations and those of the aircraft.

After demonstrating a series of turns and a straight and level stall, the PIC selected 50 per cent flap, rolled the aircraft into a left turn at about 25° angle of bank, reduced the power to idle, and raised the nose of the aircraft. The right wing dropped rapidly and the aircraft entered a spin to the right. When about 2,000 ft above ground level, the PIC was unsure whether he then had enough height remaining to recover control of the aircraft, and elected to deploy the aircraft’s parachute. The rocket fired, the aircraft initially pitched up slightly and then as the parachute deployed, the aircraft pitched down rapidly into a nose low attitude. About 6 seconds after the rocket fired, the right snub line of the parachute released, followed by the left snub line, which then established the aircraft in a wings level attitude.

The aircraft narrowly avoided powerlines, collided with branches of a tree, and came to rest on a fence in the garden of a residential dwelling.

This incident provides a reminder to pilots to know your own limitations and those of the aircraft. This demonstrates the importance of thorough planning and preparation for every flight and also of re-assessing when forced to deviate from the plan, such as operating over higher terrain. Thorough passenger and student briefings conducted prior to the flight may assist in dealing with emergency situations. 

Read the final report: Loss of control involving a Cirrus SR22, N802DK, near Katoomba, New South Wales, on 10 May 2014

On 17 February 2014, a Cessna C206 aircraft, registered VH-YOT, departed runway 05 at Newman Airport, Western Australia, at about 0526 Western Standard Time (WST) for a charter flight to Cotton Creek in visual meteorological conditions. The pilot was the only occupant.

About 3 minutes after take-off, while in the climb and at about 1,500 feet above ground level, the pilot conducted a scan of the aircraft instruments and noticed that the engine oil pressure gauge was indicating zero. All the other engine instrument indications were in the normal range and the pilot tapped the oil pressure gauge but the indicator did not move. The pilot turned the aircraft back towards Newman airport. About 1 minute later, the pilot observed sparks coming from the engine cowling near the propeller, the engine power decreased and a severe vibration was felt through the airframe. The pilot pulled the mixture control to lean cut off to stop fuel flowing to the engine as he was concerned about an inflight fire and the propeller stopped rotating.

This accident highlights the importance of pre-flight decision making and planning for emergencies and abnormal situations.

The pilot determined that he would not be able to glide to runway 23 and began a scan to locate a suitable landing area that was away from power lines in the area. The pilot located a paddock that was about 4 km from the airport that appeared to be a suitable landing area and was near a dirt road. As the aircraft got closer to the landing area, the pilot could see what he initially thought was small shrubs, was actually medium sized trees. Prior to landing, the pilot shut down all non-essential aircraft systems.

On landing, the left wing impacted a tree and the aircraft spun around 180 degrees. The left wing was bent obstructing the only cockpit exit door. The fuel system had been disrupted and fuel was quickly entering the cockpit area. The pilot shut down all remaining systems and climbed into the rear section of the aircraft. The forward section of the cargo door was obstructed by the flaps in the full down position. The pilot exited the aircraft through the rear section of the cargo door and was not injured. The aircraft was substantially damaged.

Read the final report: Engine failure involving a Cessna C206, VH-YOT, 4 km east-north-east of Newman Airport, Western Australia, on 17 February 2014

Additional reading: Managing partial power loss after take-off in single-engine aircraft

On 30 April 2014, the pilot of a Cessna 172 aircraft, registered VH-MKQ, was conducting a private flight from Launceston to a landing site about 13 km south-west of Launceston, Tasmania. Prior to departing Launceston, the pilot completed two circuits with stop-and-go landings, and confirmed the brakes were operating normally.

After a flight of about 6 minutes, the aircraft arrived overhead the landing site and the pilot overflew four times to assess the field. The pilot then conducted the approach as planned, however, when on final, he determined that the aircraft was too high and too fast to land so he conducted a go-around. 

This incident highlights the importance of considering all of the factors when assessing a landing area.

On the second approach, the pilot established the aircraft on final, with full flap selected, and slightly lower and slower than the previous approach. The wheels touched down at the pilot’s selected point, and the aircraft bounced slightly. The pilot applied the brakes, and the aircraft began to decelerate, however, as he increased the pressure on the brakes, the brakes locked up and the aircraft continued towards a fence.

The pilot selected the fuel mixture to idle cut-off and the engine stopped. The aircraft collided with the fence and the nose landing gear entered a ditch. The aircraft nosed over and came to rest inverted. The aircraft was substantially damaged, and the pilot was uninjured.

This incident highlights the importance of considering all of the factors when assessing a landing area. The stopping distance required by an aircraft may vary considerably depending on the surface conditions.

Read the final report: Runway excursion involving a Cessna 172, VH-MKQ, 13 km south-west of Launceston, Tasmania, on 30 April 2014