On 4 June 2013, track workers were preparing a road-rail vehicle to travel to a worksite near Rinadeena Station on the West Coast Wilderness Railway, Tasmania, when the vehicle unexpectedly started to roll backwards down a 1:20 grade. The driver was unable to slow the vehicle, so he and the passenger jumped clear, sustaining minor injuries.

The now unmanned out-of-control vehicle continued to accelerate down the steep grade, heading towards a second road-rail vehicle containing four track workers. Two passengers of the second vehicle jumped clear, sustaining minor injuries, but a third passenger and the driver were still inside when the unmanned road-rail vehicle collided with theirs.

The passenger sustained minor injuries, but the driver was trapped and seriously injured in the collision. He was subsequently removed from the vehicle and air lifted to hospital. Both road-rail vehicles were extensively damaged.

The ATSB found that the vehicle’s rear road tyres were lifted from the track to examine a suspected problem with the rear rail guidance wheels. As a result, the braking force provided by the rear road wheels was lost and the vehicle began to roll down the incline. The rail guidance wheel electric brake controller had not yet been set correctly and, as a result, little braking effort was applied through the rail guidance wheels.

... the driver was trapped and seriously injured in the collision. He was subsequently removed from the vehicle and air lifted to hospital.

The investigation also found that the West Coast Wilderness Railway had not considered all of the risks associated with the operation of road-rail vehicles on the steep railway. As a result, documented operational procedures had not been developed and locations where vehicles could be safely on and off railed had not been defined.

Other findings related to the effectiveness of the training provided to the road-rail vehicle operators, road-rail vehicle procurement standards, acceptance testing and commissioning of road-rail vehicles, reliability of the very high frequency (VHF) radio network in the Rinadeena area and radio communication protocols.

West Coast Wilderness Railway has reviewed its risk register and implemented operational procedures covering the safe operation of road-rail vehicles on the network. This has led to the development and implementation of an updated training package, procurement specifications and documented on/off tracking points. The company has also taken action to improve radio reception in the Rinadeena area and to ensure reliable communications at the station.

All organisations operating road-rail vehicles should consider the risks associated with operating the vehicles on their networks. Information on the risk of operating road-rail vehicles can be found at the Office of National Rail Safety Regulator website(Opens in a new tab/window).

Read the final report: Collision between two road-rail vehicles, near Rinadeena, Tasmania, on 4 June 2013

Additional reading - SafetyWatch: Safe work on rail

A pilot died after the canopy of his aircraft opened, interfering with his attempt to land safely.

On 18 September 2013, the pilot of an amateur-built Lancair Legacy aircraft was taking off from Geraldton Airport in Western Australia. He began the take-off roll with substantial engine power and the aircraft accelerated normally to about halfway along the runway. At this point, however, an observer saw smoke from the main wheels, indicating that the brakes were applied momentarily. At the same time the forward-hinged canopy opened about 15 to 30 cm. The pilot did not reject the takeoff, and instead the aircraft lifted off and climbed to about 100-150 ft above ground level.

The ATSB investigation found that while the canopy had been down during the takeoff, it had inadvertently been left unlatched.

The pilot banked the aircraft to the left and during the turn the canopy opened further so that it was at an estimated angle of 30°. The pilot appeared to be manoeuvring for a landing but the aircraft undershot the approach and the wheels hit a road kerb short of the airport perimeter. The aircraft then collided with the perimeter fence and became entangled as it overturned. Shortly after, an intense fire engulfed the aircraft.

Bystanders tried to extinguish the fire with handheld fire extinguishers and a water truck from a nearby worksite but their efforts had no immediate effect. The pilot was rescued from the wreckage and treated for burns, but later succumbed to his injuries.

The ATSB investigation found that while the canopy had been down during the takeoff, it had inadvertently been left unlatched. During his manoeuvring for landing, the pilot had likely encountered control, performance and forward visibility difficulties from the open canopy, affecting the capacity to conduct a normal approach.

The ATSB advises owners, operators and pilots of aircraft with canopies to review the adequacy of their current measures that are intended to ensure canopies are securely latched before flight (such as pre-take-off checks and warning systems), and the actions in case of inadvertent canopy opening during takeoff.

From the momentary brake application when the canopy came open it appears that the pilot’s initial reaction, perhaps instinctive, was to reject the takeoff. However, engine power was not reduced and the takeoff was continued. The decision to stop or go when an aircraft is close to lifting off can be a difficult one. The ATSB advises that, where possible in abnormal situations, pilots should take time to assess the nature of the abnormality to rectify the situation or mitigate the effects.

Read the final report: Canopy-related landing accident involving Lancair Legacy, VH-ALP, Geraldton Airport, Western Australia, on 18 September 2013

At about 1200 on 15 September 2013, the pilot-owner of a Cessna 206, registered VH-WAV, landed on a public road to repair a truck at a work camp. At about 1516, during take-off from a different, curved road, the aircraft’s left wing struck a tree at a height of about 30 ft. The wingtip and aileron separated before the aircraft impacted terrain, fatally injuring the pilot and passenger. The aircraft was destroyed.

The distance available from where the pilot increased power for take-off was much shorter than the distance advised in the aircraft’s pilot operating handbook under the prevailing conditions.

The accident highlights the importance of carefully considering all relevant factors that could affect the suitability of a particular landing and take-off area.

There was no apparent reason for the pilot to attempt a take-off from that location when a more suitable location was nearby. It is most likely that the pilot misjudged the distance available, the prevailing conditions and their effect on the aircraft’s performance, or had a false recollection of the relative layout of the two roads and thought that there was more take-off room available beyond the curve. However, it is also possible that the pilot’s judgement of the available distance, or his decision-making capability, was affected by a serious medical condition and/or prescribed medications that had not been reported to the Civil Aviation Safety Authority (CASA) until after the pilot’s previous medical certificate had expired.

In addition, the ATSB found that the pilot’s seat had broken from its mounts, probably as the result of heavy, unsecured cargo striking it during the accident sequence. This could have had a detrimental effect on the survivability of the accident.

The accident highlights the importance of carefully considering all relevant factors that could affect the suitability of a particular landing and take-off area. These include: aircraft weight and engine power; wind direction, speed and gusts; ambient air pressure and temperature; surface slope, material, and condition; other physical characteristics of the area such as its length and width; and the height and location of surrounding obstacles.

Though no link with the accident was established, flying without a valid medical certificate, or omitting to report a diagnosed condition or treatment to a Designated Aviation Medical Examiner or to CASA, can lead to such an impairment being undetected or its effect underestimated.

Unrestrained cargo poses a significant risk to the survivability of aircraft occupants. Pilots should take care to ensure that all cargo is adequately restrained to prevent movement during flight and improve survivability in the event of an accident.

Read the final report: Collision with terrain involving Cessna 206, VH-WAV, 156 km south-south-east of Croydon, Queensland, on 15 September 2013

Additional reading: SafetyWatch - General Aviation

On the afternoon of 8 February 2013, the 42 m Cayman Islands registered motor yacht Calliope departed from the Sydney Superyacht Marina in Rozelle Bay for a cruise around the harbour.

As Calliope transited the Glebe Island Bridge, it was off course and veered towards the bridge structure. To minimise any damage to the vessel, the crew attempted to walk a fender between the yacht’s hull and any possible points of contact. During this process, a crew member, leaning over the side of the yacht positioning the fender, was caught between the yacht and one of the bridge mounted fenders. The crew member was pulled over the yacht’s side and into the water.

The crew member was retrieved from the water shortly afterwards but died as a result of the injuries he had sustained.

The ATSB found that a passage plan for the voyage had not been completed and, therefore, the risks associated with the voyage were not appropriately assessed or communicated to the crew. It was also determined that the yacht’s master could not reference any navigational aids from his conning position in front of the navigational bridge. Hence, he was not in a position to properly monitor the yacht’s progress.

Flag States and port administrations should consider the risks associated with operating a vessel when determining regulatory compliance requirements...

The ATSB also concluded that while Calliope was in voluntary compliance with elements of the Large Commercial Yacht Code (a United Kingdom instrument which had been adopted by the Cayman Islands), the yacht did not have to comply with these requirements because it was deemed to be a pleasure yacht. Similarly, the yacht did not have to carry a pilot while operating in Sydney Harbour because it was considered to be a recreational craft.

Calliope’s management company has advised that the ship’s safety management system procedures have been updated to require the completion of a passage plan for all voyages. Procedures for transiting bridge openings will be also be issued. A specialist consultant will also be engaged to conduct on board audits of the safety management system.

The Cayman Islands Shipping Registry has advised that the effectiveness of the Large Commercial Yacht Code in meeting the fundamental requirements of a documented safety management system will be raised with the United Kingdom as the authors, publishers and custodians of the Code.

The harbour master for the Port of Sydney has highlighted the details of this accident as part of a review of the NSW Marine Safety Act.

Flag States and port administrations should consider the risks associated with operating a vessel when determining regulatory compliance requirements, rather than making such determinations based on the vessel’s mode (commercial or private) of operation.

Read the final report: Fatality on board the motor yacht Calliope, Rozelle Bay, New South Wales, on 8 February 2013

Additional reading: SafetyWatch - Marine work practices

On 3 July 2013, a company representative was boarding the bulk carrier Atlantic Princess via the ship’s pilot ladder when he fell and landed on the deck of the pilot launch below. At the time, the ship was at anchor off Whyalla, South Australia, loading iron ore from an offshore transhipment barge.

The injured man was provided with immediate first aid and transported to the local hospital. However, he died later that day as a result of his injuries.

The ATSB found that while Atlantic Princess’s pilot ladder had been rigged in accordance with the relevant international requirements, no further risk assessment was carried out for the personnel transfer. The investigation also found that the company’s safety management system provided no guidance relating to actions that should be taken when less experienced personnel were to use a pilot ladder to board or disembark the ship.

This accident highlights the fact that while pilots may be competent in the use of pilot ladders, it should not be assumed that other personnel are proficient in climbing or descending a pilot ladder, or fit to do so.

In addition, there were no facilities on board the transhipment barge that could be used to provide a safe means of access between the barge and the ship for personnel transfers with the barge operator’s procedures prohibiting such transfers.

The investigation also identified safety issues relating to the content and implementation of the pilot launch operator’s safety management system.

The ship’s managers have issued a fleet safety circular noting that helicopters should be used for transfers of persons other than pilots wherever possible. When this is not possible, they are required to use a safety harness while climbing a pilot ladder. These requirements are to be advised to the ship’s agent in advance.

The pilot launch operator’s safety management system has been audited and the company is working to improve the system and its implementation. The company’s personnel transfer procedures have also been updated.

This accident highlights the fact that while pilots may be competent in the use of pilot ladders, it should not be assumed that other personnel are proficient in climbing or descending a pilot ladder, or fit to do so.

Read the final report: Fall from the pilot ladder on the bulk carrier Atlantic Princess, Whyalla, South Australia, on 3 July 2013

Additional reading: SafetyWatch - Marine work practices

On 23 February 2014, a Hughes 269C helicopter, was parked on a property about 55 km north-east of Launceston, Tasmania, beside a dam. The pilot had shut the helicopter down in that position about a week earlier, aware that it was low on fuel.

At about 0700 Eastern Daylight-savings Time (EDT), the pilot prepared for a short 200 m flight to reposition the helicopter to the other side of the dam, for refuelling. He conducted fuel drains, with no contaminants found.

While experience and familiarity with operations are invaluable, they can also lead to complacency.

The helicopter took off and climbed to about 20 ft above ground level. When about three quarters of the way across the dam, the engine stopped due to fuel exhaustion. The pilot conducted a forced landing onto the edge of the dam, with part of the helicopter sinking into the water and mud. The main rotor blades collided with the embankment resulting in substantial damage.

While experience and familiarity with operations are invaluable, they can also lead to complacency. It is therefore important that pilots with experience, familiarity and comfort with the aircraft and location, continue to do all checks thoroughly.

Read the final report: Fuel exhaustion event involving a Hughes 269C, VH-HAK, 55 km north-east of Launceston Airport, Tasmania, on 23 February 2014

Additional reading:

• Avoidable Accidents No. 5 – Starved and exhausted: Fuel management aviation accidents
• Avoidable Accidents No. 6 - Experience won’t always save you

On 11 October 2013, the student pilot of a G-115C2 Grob aircraft, registered VH-ZIV, departed the Merredin aeroplane landing area (ALA) on his first solo flight to the designated training area located near Lake Brown, Western Australia.

After about 1.4 hours the student elected to return to Merredin, tracking via Burracoppin Township. The student was unable to sight Merredin (ALA) and broadcast on the universal communications (UNICOM) frequency indicating that he was unsure of his position. The UNICOM operator gave him directions to locate Merredin.

While pilots conduct a pre-flight inspection of their aircraft to determine airworthiness, this accident highlights the importance of pilots also assessing their own wellbeing.

The student located Merredin and joined the circuit for runway 28. When on short final he determined that he was too high and initiated a go-around. The student commenced a second circuit to runway 28. When on short final, the student reported there was a crosswind with slight windshear, and the glare from the sun was making it increasingly difficult to see the runway. The aircraft touched down heavily and bounced. The student reported that the sun glare made it very difficult to judge the height of the aircraft and he believed that the aircraft had not bounced very high. At about 1700 Western Standard Time the aircraft touched down again on the nose landing gear, which subsequently collapsed. The aircraft slid along the runway and came to a stop. The student pilot was uninjured and the aircraft sustained substantial damage.

The aircraft operator conducted an internal investigation and determined the student’s last meal was at 0600, which consisted of a sandwich and the operator’s flight risk assessment tool (FRAT) for the accident flight was incomplete. If all values for the flight had been entered, the total risk value for the flight would have been in the red area stating ‘No dispatch’.

The student indicated he had about 6 hours sleep the night before the accident as he was finishing his ground school homework and preparing for the next day.

This accident highlights the importance of pilots also assessing their own wellbeing, to determine if they are physically and mentally prepared, and if the operating conditions are suitable for the conduct of the flight. The effect of sun-glare when relying on visual cues is an important consideration for all pilots.

Read the final report: Hard landing involving a Grob G-115C2, VH-ZIV, Merredin (ALA), Western Australia, on 11 October 2013

A coastal pilot disembarking from the chemical tanker Golden Concord fell 3 m to the deck of a pilot launch when the pilot ladder manrope he was holding appeared to give way.  

Pilot transfers by way of pilot ladders are routine, yet inherently risky operations. They require the correct configuration of the pilot ladder and manropes and clear and standardised communication between the ship’s crew, the pilot and the pilot launch crew.

Fortunately, in this case the pilot did not sustain any serious injuries. However, the ATSB found a number of risk controls designed to prevent such an occurrence had been compromised.

Following this incident, the ship’s management company has revised its pilot transfer procedures to ensure that all transfers are conducted with a deck party consisting of a supervising officer and at least one deck rating. The company has also revised its procedures to ensure that pilot ladders and manropes are rigged in accordance with the most recent international requirements.     

The pilotage company has revised its procedures to incorporate the provision of information about the use of manropes to pilot launch crews on their approach to the ship. Pilots and launch deckhands are now required to conduct a visual and manual check of pilot ladders before disembarking. The company is also reinforcing the importance of adhering to the standard communication protocols specified in the safety management system.

Read the final report: Fall from the pilot ladder on board the chemical tanker Golden Concord, Goods Island, Torres Strait, Queensland, on 4 July 2013

An aircraft separation incident between an unmanned aerial vehicle and crop duster highlights the challenges with having a diverse mix of aircraft operating in the same airspace.

On 12 September 2013 the pilot of an Ayres S2R commenced aerial agricultural spraying operations on a property near Horsham, Victoria. At about the same time, the operator of a UAV, Sensefly eBee 178, arrived at ‘Iluka Echo’ (Echo) mine site to conduct an aerial photography survey of the site. After completing his pre-flight preparation and risk assessment of the operation, the operator heard an aircraft operating about 1 – 1.5 km away on a neighbouring property.

Pilots of UAVs are required to operate at or below 400 ft but approval can be granted to operate higher...

The UAV operator broadcast on the area frequency advising his intention to conduct unmanned aerial photography operations over the Echo mine site but did not receive a response. He then asked the mine manager to contact the farmer, who was loading fertiliser into the hopper of the Ayres aircraft to advise him of the UAV operating in the area and advise the pilot.

The UAV then commenced operations. After completing the first load of fertiliser the pilot of the Ayres aircraft reported that the farmer informed him that there would be an ‘aircraft’ conducting aerial photography over the mine site, near one of the areas he would be operating on. The pilot assumed that this would be a fixed-wing aircraft operating at or above 500 ft AGL. Accordingly, he intended to remain at or below 350 ft to ensure separation.

During their operations the two aircraft came within 100 m of each other. The pilot of the Ayres reported that he did not see the UAV at any time, although he was aware of a white vehicle parked on the road. He was not aware of the procedures for UAV operations. The UAV operator advised that in future, even if unable to contact the pilot via radio, he would ensure he spoke directly to the pilot of any aircraft operating in the same area as the UAV. This would assist in increasing awareness and understanding of UAV operations.

Pilots of UAVs are required to operate at or below 400 ft but approval can be granted to operate higher—in this case a NOTAM would be issued (A NOTAM is a notice filed with Airservices to alert other pilots of potential hazards.) All UAV operators are also required to broadcast on the appropriate frequency. Pilots and operators need to remain vigilant and employ ‘see and avoid’ principles and they need to recognise that small UAVs may be difficult to see.

Read the final report: Aircraft separation issues involving an Ayres S2R, VH-WBK, and an unmanned aerial vehicle, 37 km south-south-west of Horsham Airport, Victoria, on 12 September 2013