An Airbus A320-232 descended below two minimum safe altitudes.

The ATSB reminds operators and flight crew of the vital importance of continuous attention to active and armed auto-flight system modes. This reminder comes after an incident which occurred on 16 July 2012 as an Airbus A320-232, operated by Jetstar Airways, was arriving at Queenstown International Airport, New Zealand.

The aircraft was conducting an instrument approach to runway 05 using the aircraft auto-flight system. The approach consisted of a series of progressively lower steps that signified the minimum safe altitude for each segment of the procedure.

The crew intended to select an auto-flight system mode during descent that would have ensured compliance with procedure minimum safe altitudes, but overlooked that selection. As a result, the aircraft continued descent in an unintended mode that did not prevent infringement of minimum safe altitudes. The aircraft consequently descended beneath the minimum safe altitude of two segments of the approach procedure. Upon recognising the descent profile problem, the crew climbed the aircraft to intercept the correct path and continued the approach to land safely.

The ATSB found that the crew were not strictly adhering to the operator’s sterile flight deck procedures...

Although the aircraft was below the minimum safe altitude during two segments of the approach, a collision with terrain was never likely given the fine and clear in-flight conditions. No Ground Proximity Warning System alerts were generated during the incident.

The ATSB found that the crew were not strictly adhering to the operator’s sterile flight deck procedures, which restrict flight deck conversation during the safety-critical and high workload phases of flight to important operational matters. This probably allowed the crew to become distracted and not notice that descent was continuing in an unintended auto-flight system mode. Also, the operator’s procedures did not specifically draw the crew’s attention to unchanged auto-flight system modes during descent.

Following this occurrence, the operator included additional guidance material in its Flight Crew Training Manual regarding mode awareness. It also included a warning on its Queenstown approach charts.

It is important that crews continually monitor descent profiles in relation to approach procedure minimum safe altitudes, irrespective of any expectation that the descent is being appropriately managed by the auto-flight system. This occurrence also highlights the importance of robust auto-flight system management procedures.

Read the final report: Descent below segment minimum safe altitudes involving Airbus A320-232, VH-VQA, near Queenstown, New Zealand, on 16 July 2012

On 28 August 2013, at 1:30 in the morning, the pilot of a Fairchild SA227 took off from Brisbane for Bankstown, only to find the right wing of the aircraft dropping markedly.

There had been issues with the aircraft’s fuel balance earlier in the day, and the left fuel quantity gauge had been identified as unserviceable, but the pilot had believed that the imbalance issue had been addressed. Clearly, that was not the case.

Thankfully, the weather was fine and the night was bright, and the pilot was able to establish a visual reference and maintain control of the aircraft. He raised the right wing, and opened the fuel cross-flow valve to rebalance the aircraft. After about two minutes, the aircraft was rebalanced, and he closed the cross-flow valve. The aircraft continued to handle normally during the flight until the descent when, at about 400 ft above ground level, the right wing suddenly dropped again. The pilot raised the right wing and elected to continue the approach, landing without further incident.

This incident has demonstrated the importance of thorough pre-flight preparation in particular with regard to fuel planning and loading.

The events that led up to this dangerous situation were characterised by a series of miscommunications and assumptions. Earlier that day, the aircraft had been flown from Cairns to Brisbane. The pilot of that flight (who would not be flying the aircraft on its next leg) had advised the engineering staff that the fuel tanks were out of balance and the left fuel quantity gauge was unserviceable. The pilot and engineers rebalanced the fuel tanks in accordance with the company procedures.

The pilot of the next flight then requested that additional fuel be uploaded due to the forecast weather at Bankstown.  A staff member, noting the recorded imbalance and unaware that the previous pilot and engineers had corrected the problem, placed more fuel in the right tank, once more bringing the aircraft out of balance.

When it came time for the pilot to establish the fuel quantities, he could not use the fuel gauge, and so he made the calculation using information from the fuel log and the remaining fuel gauge. The additional fuel and the company’s procedures for estimating fuel, however, resulted in the pilot unknowingly taking off with a fuel imbalance of 100 L between the tanks.

This incident has demonstrated the importance of thorough pre-flight preparation in particular with regard to fuel planning and loading. As a result of the occurrence, the aircraft operator is instituting several safety actions to ensure that there will be no repetition of the circumstances which could have so easily turned disastrous.

Read the ATSB investigation report, AO-2013-196 for information and strategies on ensuring fuel safety.

The ATSB is reminding pilots of the dangers of aerodynamic stall, after a student pilot and instructor were killed after their aircraft collided with terrain.

The accident occurred on 9 November 2012 near Lismore Airport, New South Wales where the student and instructor were conducting circuit training flights in a SOCATA TB 20. The ATSB found that while making a left turn in the circuit, an aerodynamic stall occurred, resulting in a significant left-wing low and nose-down attitude in close proximity to the terrain. The aircraft collided with terrain in a paddock, about 3 km south of Lismore Airport. Both occupants received fatal injuries, and the aircraft was destroyed by the impact and an intense fuel-fed, post-impact fire.

...the aircraft stalled at such a low altitude that they were unable to recover fully to controlled flight before the aircraft collided with terrain.

Either because of insufficient warning or lack of time to react, the instructor was unable to prevent the stall from occurring. Although it appeared that a stall recovery was commenced, the aircraft stalled at such a low altitude that they were unable to recover fully to controlled flight before the aircraft collided with terrain.

The ATSB also found that the aircraft’s engine contained crankcase through bolts from a different engine manufacturer that were installed in the engine prior to the aircraft’s importation into Australia and were probably unapproved for use in that engine. Although these bolts did not contribute to the accident, their installation meant that the continued safe operation of the engine could not be assured.

The accident highlights the need for pilots to minimise the risk of aerodynamic stall, particularly when in proximity to the ground, such as during take-off and landing.

In addition, aircraft owners and maintainers should ensure that all parts fitted to their aircraft are appropriately approved for the application.

Read the final report: Loss of control involving SOCATA TB 20, VH-HBB, 3 km south of Lismore Airport, New South Wales, on 9 November 2012

Rail operators are being encouraged to use independent data validation systems, such as forward facing video, on trains, after an ATSB investigation into a signal irregularity could not substantiate the observations of the train crew.

The braking distance for freight trains can be significant so train drivers must begin braking well in advance of a projected stopping point. As a result, train drivers need advance information about the status of fixed signals ahead of the train movement.

The incident occurred on 7 April 2013, as a southbound freight train was travelling at 115 km/h on the main line of the Culcairn North passing loop in New South Wales. The train consisted of four locomotives hauling 37 wagons having a total length of 1,489 m and a trailing mass of 2,561 t.

The ATSB encourages all rail operators to consider the use of independent data validation systems, such as forward facing video on trains...

The driver and second person of the train would later report that, as they approached a signal designated DIS-CN03, it was displaying a clear (green) indication. As a result, they expected that the next signal, CN03, would be at ‘proceed’ and that the track ahead would be clear of any opposing train. After passing signal DIS-CN03 and rounding a sweeping right hand curve, however, the driver saw the headlight of an opposing train and that home signal CN03 was set at ‘stop’ (red).

The driver immediately made an emergency brake application to stop the train, which averted a collision with the opposing train. There were no injuries or damage as a result of this occurrence.

The ATSB investigation of the available evidence showed that the signalling system was operating correctly at the time of the incident and therefore the signal (DIS-CN03) preceding the signal at stop (CN03) should have been displaying a caution aspect (yellow). However, the crew were adamant that the signal DIS-CN03 had been at green.

As the train was not fitted with forward facing video equipment, the ATSB was unable to substantiate the train crew’s observations of signal DIS-CN03.

The Australian Transport Safety Bureau encourages all rail operators to consider the use of independent data validation systems, such as forward facing video on trains, to provide a source of information to assist in coming to an understanding of rail occurrence events, such as signal irregularities.

Read the final report: Signal irregularity reported by crew of train 5BM7, Culcairn North, New South Wales, on 7 April 2013

Owners of certain ships are being warned of a dangerous drainage system modification that contributed to the death of an engineer.

The accident occurred on 20 March 2013, on board the bulk carrier Nireas. The ship was anchored off Gladstone, Queensland, and an engineer was carrying out the routine task of draining water from the ship’s main air receiver (part of the compressed air system). Unbeknownst to the engineer, as he continued with his task the pressure from the air receiver was affecting another component, the drainage pot. The drainage pot was a heavy steel cylinder mounted into the deck adjacent to the air receivers. The pressure built within the pot until, eventually, the drainage pot observation window exploded. Tragically, the engineer was killed by flying debris.

The ship builder contacted all owners of ships in which it had fitted this design of drain system to warn them.

The ATSB investigation found that the original designers of the system had assumed that it would be open to the atmosphere. The modifications to the design, however, had created a closed system, allowing the pressure to affect the drainage pot. The shipyard had not ensured that the new design was adequately engineered, tested and approved prior to installation, despite having procedures in place which should have ensured such scrutiny. 

Furthermore, the ATSB learned that similar designs of drainage systems had been, and continued to be, fitted in ships by various shipyards around the world.

In response to the accident, the ATSB issued a safety advisory notice to all classification societies, advising them of the accident and its safety implications. The ship builder contacted all owners of ships in which it had fitted this design of drain system to warn them. They informed them of the accident and requested that all observation glasses be removed and for the pots to remain unobstructed.

The Australian Maritime Safety Authority issued a Marine Notice to draw industry attention to this accident and its causes.

This accident highlights the need to follow a formal process of risk assessment when considering possible equipment modifications. Such a process must ensure that all associated risks are identified, considered and appropriately treated.

Read the final report: Crew member fatality on board the bulk carrier Nireas, while at anchor off Gladstone, Queensland, on 20 March 2013

A severe-turbulence incident involving a Boeing 767 shows why it’s crucial to securely stow all carry-on baggage, including laptops and iPads, during flight.

On 8 November 2013, the Boeing 767 experienced severe turbulence while descending into Sydney. The turbulence lasted for about 2 minutes and the crew discontinued the approach and initiated a go-around. During the climb of the go-around, the aircraft experienced more turbulence, and one passenger sustained a serious head injury from a laptop computer that fell from an overhead locker. Another received a rib injury and a third was injured by an iPad.

After circling for about 20 minutes, a further attempt to land was affected by turbulence. The crew declared a PAN and diverted to Williamtown, New South Wales. After landing safely, the injured passengers were transported to hospital for treatment.

This incident is a timely reminder for passengers to stow all carry-on baggage securely in the overhead lockers...

Before departure from Melbourne, weather reports had only indicated the possibility of moderate turbulence below 5,000 ft. After the incident, the Bureau of Meteorology reported that a strong and gusty south-westerly change had produced windshear as the change encountered the north-easterly sea-breeze. This sudden change affected the landing.

This incident is a timely reminder for passengers to stow all carry-on baggage (including laptops and iPads) securely in the overhead lockers or under the seat in front of them, especially when the seatbelt sign is turned on. These items can become projectiles during turbulence if not properly secured.  

The ATSB’s Aviation Safety Bulletin Staying Safe against In-flight Turbulence identified that 99 per cent of people on board an aircraft receive no injuries during a typical turbulence event. However, in recent research, the ATSB is seeing a doubling of turbulence and windshear events in passenger operations, some affecting the safety of those in the cabin.

Read the final report: Turbulence event involving a Boeing 767, VH-OGU, near Sydney Airport, New South Wales, on 8 November 2013

The ATSB is urging drivers to show caution after an accident in Victoria destroyed a dog trailer being towed by a truck and caused significant damage to a locomotive and 75 m of track infrastructure.

The accident occurred on 7 September 2013 at the Pettavel Road level crossing at Mount Moriac, 20 km west of Geelong. A V/Line passenger train was operating the scheduled service from Melbourne to Warrnambool, Victoria. As the train approached the level crossing, two trucks that were transporting soil from a development site turned onto Pettavel Road. The Pettavel Road level crossing was equipped with approach warning signage and Stop signs for each road approach.

The locomotive came to a stand about 315 m past the level crossing. Five passengers, the locomotive driver and a conductor sustained minor injuries in the collision.

The train driver saw the trucks approaching and sounded the whistle multiple times. As the train drew closer to the crossing, the train driver decided that the trucks may not have been alerted to the train’s approach and applied the emergency brakes and braced for the collision.

The leading truck drove through the level crossing and the second truck, a rigid truck and dog trailer combination followed. As the second truck passed through the crossing the locomotive, which had decelerated to a speed of about 101 km/h, collided with the truck’s dog trailer, which was carrying about 12 cubic metres of soil.

The locomotive came to a stand about 315 m past the level crossing. Five passengers, the locomotive driver and a conductor sustained minor injuries in the collision. The truck driver was not injured, but the collision destroyed the dog trailer, and caused significant damage to the locomotive and approximately 75 m of track infrastructure.

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

Read the final report: Collision between a truck and passenger train 8205, Pettavel Road Level Crossing, Mount Moriac, Victoria, on 7 September 2013

Transport aircraft operators are being encouraged to review crew guidance to ensure the risk of windshear associated with thunderstorms and dry microbursts is effectively managed.

This advice follows the 19 October 2012 hard landing of a Fokker F100 aircraft at Nifty Aerodrome in the Pilbara region of Western Australia.

While the flight crew were positioning the aircraft for a 5 NM (9 km) straight-in approach into a slight headwind, they received a windshear caution. In response, the crew increased the approach speed and extended the speed brake to stabilise the approach. The approach continued and apart from a few minor speed variances, the conditions seemed relatively benign.

The ATSB found that when the aircraft was on approach to land at about 80 ft above ground level the flight path almost certainly coincided with a strong outflow of a dry microburst.

As the aircraft was in the final stages of the approach and descending from 80 ft to 30 ft above ground level, the airspeed dropped from 133 kt to 110 kt and the rate of descent increased to about 1,000 ft/min. The loss of airspeed occurred over a period of 3 seconds and by touchdown, the aircraft was being affected by a 32kt tailwind.

The aircraft touched down on the runway threshold, almost 300 m short of the normal touchdown point, and bounced. The high rate of descent resulted in a hard landing with significant damage to the aircraft. None of the crew or passengers were injured.

The ATSB found that when the aircraft was on approach to land at about 80 ft above ground level the flight path almost certainly coincided with a strong outflow of a dry microburst. A dry microburst is a column of rapidly descending air that can produce damaging and divergent winds when it reaches the ground. They are initiated by evaporative cooling and are generally associated with high-based cumulous cloud. The scale and suddenness of a microburst makes it a great danger to aircraft.  This resulted in a performance-decreasing windshear that led to the serious drop in airspeed, high sink rate, undershoot and a hard landing.

As a result of the occurrence, the operator sought to improve the weather information available at aerodromes serviced by their F100 fleet and modified its simulator training program along with consolidation of the windshear procedures and guidance. The operator also provided additional guidance in the use of the flap following receipt of a windshear caution during approach and planned to introduce a new threat-based take-off and landing briefing model.

Read the final report: Windshear-related hard landing involving Fokker 100, VH-NQE, Nifty Aerodrome, Western Australia, on 19 October 2012

A collision with a passenger train at a level crossing sent a utility vehicle spinning off the track, leaving the motorist seriously injured.

The ATSB is once again warning the drivers of motor vehicles to be vigilant at railway level crossings after an accident in Inverleigh, Victoria.

The accident occurred on 31 August 2013, when the passenger train known as The Overland was travelling from Melbourne to Adelaide. At around 10.00 am, as the train approached the Mahers Road level crossing at Inverleigh (about 27 km west of North Geelong), the level crossing flashing lights, bells and boom barriers began to operate.

The Overland was travelling at 78 km/h, with its headlight illuminated. As it drew near to the level crossing, the crew saw a Holden Rodeo dual cab utility travelling along an unsealed maintenance access track adjacent to the railway.

This accident highlights the need for road and rail authorities to work together in maintaining the integrity of fences and structures to exclude public access to the railway corridor.

The utility continued along the access track and then, to the train crew’s surprise, it entered Mahers road and turned into the lowered level crossing boom barrier, striking the end of the boom. The utility came to a stand across the railway line.

The train driver made an emergency brake application, but the train could not be stopped in time and collided with the front of the utility. The utility was spun around, and it came to a rest on the side of the track. The train stopped about 370 m beyond the level crossing. The sole occupant of the utility was seriously injured and transferred to Royal Melbourne Hospital. The locomotive crew suffered from shock, but none of the train’s 103 passengers were injured.

The ATSB investigation found that the road used by the utility, known locally as the ‘Gallagher Road Extension’ was, in fact, a railway maintenance access track located entirely within the railway corridor on land leased by the Australian Rail Track Corporation. Nevertheless, many commercial mapping providers, including VicRoads, had incorrectly identified the maintenance access track as a road. It was regularly used by local traffic, but since it was not a public road, there were no level crossing traffic control devices (flashing lights or road signage) provided.

This accident highlights the need for road and rail authorities to work together in maintaining the integrity of fences and structures to exclude public access to the railway corridor. In the wake of this accident, the Australian Rail Track Corporation and the Golden Plains Shire have advised that they will work together to isolate the rail corridor from Gallagher Road permanently.

Read the final report: Level crossing collision between passenger train 7MA8 and a dual cab utility, Inverleigh, Victoria, on 31 August 2013

A runway incursion between a Fairchild SA227 and a Bell 47G helicopter at Ballina Airport is a timely reminder that to stay safe around non-controlled aerodromes, pilots need to monitor and broadcast on the CTAF and maintain a good lookout.

On 9 October 2013 the helicopter was conducting circuit training with an instructor and a student pilot on board. The Fairchild was about to commence its take-off. After broadcasting a lining-up and rolling call, which was acknowledged by another pilot inbound to Ballina, the pilot of the Fairchild commenced the take-off run. Just before rotation he saw the helicopter stopped on the runway towards the departure end. The Fairchild pilot increased the climb angle to maintain separation.

The helicopter instructor attempted to contact the Fairchild with no response received. She then realised that the radio volume had been turned down.

The Fairchild pilot had expected the helicopter to be conducting left-hand (not right-hand) circuits and for the helicopter to be in the air, not on the runway. After lining up, his attention had been directed inside the cockpit before commencing the take-off run.

The helicopter instructor commented that it was the end of a long hot day. She said they had been making calls on the CTAF but did not hear any broadcasts from other aircraft. While this might have indicated a radio problem, it was not unusual to have low traffic volume at Ballina at the time. Because the student was a commercial pilot, the instructor had not been monitoring the pilot’s actions as closely as she would with a low-hour student. Ballina has an aerodrome frequency response unit (AFRU) which provides an automatic response when transmitting on the CTAF. Because the radio volume was turned down the ‘beep backs’ from the system would not have been heard.

Following the incident, the operator of the Fairchild advised that they would be highlighting the importance of communication and situational awareness for all pilots. The helicopter operator advised that they would introduce a requirement into the start-up checklist for the pilot to check the automatic weather information service (AWIS). As well as providing weather information, this would enable the pilot to confirm that the radio is on and is audible.

The ATSB’s publication A pilot's guide to staying safe in the vicinity of non-towered aerodromes contains useful advice and is available from the ATSB website.  

The ATSB SafetyWatch highlights the broad safety concerns Safety around non-controlled aerodromes.

Read the final report: Runway incursion between a Fairchild SA227, VH-UZP, and a Bell 47, VH-UTF, at Ballina Airport, New South Wales, on 9 October 2013