The derailment of a loaded coal train between Emerald and Rockhampton in Queensland in January 2018 highlights the need for track managers to develop, maintain and consult network hazard registers to identify locations at risk of buckling due to compressive rail stress, according to a new ATSB investigation.

The day before the derailment, the affected track had been subject to ballast-cleaning operations. The track was then tamped, aligned, and stabilised, with a second and final pass of this work taking place the next morning.

That afternoon, as the nearly 2 km long train EF01 was descending a steep grade, the driver noticed a track buckle forming ahead of the train. After applying emergency braking the train came to a halt 65 seconds after the lead locomotive had passed over the track buckle.

The first wagon to derail travelled for over half a kilometre before the train stopped. Of the 17 wagons that derailed, 13 were extensively damaged and unlikely to be repaired. Just over half a kilometre of track on the down line and 54 m of track on the adjacent up line was damaged, with rails, sleepers and overhead line equipment needing replacement.

This investigation highlight the importance of developing, maintaining and consulting a network hazard register to identify locations at risk of buckling, and producing site-specific risk assessments that consider rail stress when planning track disturbing maintenance work.

The ATSB determined the accumulative effect of the track’s steep grade, with its proximity to a turnout and a high ambient temperature lead to the track to buckle. The ATSB also found the ballast cleaning operational plan did not consider compressive rail stress as a risk at this location.

”This investigation highlights the importance of developing, maintaining and consulting a network hazard register to identify locations at risk of buckling, and producing site-specific risk assessments that consider rail stress when planning track disturbing maintenance work,” said ATSB Director Transport Safety Dr Stuart Godley

“The accident also demonstrates that effective rail stress management is dependent on a knowledge of the rail stress free temperature and the identification of any variations from that stress free temperature.”

As a result of the accident, track manager Aurizon Network has changed its procedures to ensure a temporary speed restriction is applied to all work sites on which ballast undercutting has been performed. The restriction is to remain in place until rail adjustment or stress testing has been completed and it has been determined that the rail stresses are within accepted limits.

In addition, sites with a high risk of compressive rail stress will be identified and added to the site hazard map before conducting ballast cleaning.

Read the final report: Derailment of coal train EF01, Duaringa, Queensland, on 24 January 2018

A Robinson R44 helicopter striking a powerline while conducting aerial spraying provides another example of the dangers posed by powerlines during low-level operations, an ATSB investigation has highlighted.

The R44 was spraying weeds at Bool Lagoon, near Naracoorte, South Australia on 13 March 2019. Before the incident flight, the pilot had passed successfully under a powerline, which spanned a drainage channel to the west of Bool Lagoon, on three occasions during that days’ spraying operations.

The pilot then started a spray run from the eastern end of the drainage channel, and flew west towards a weir bridge and the powerline, which the pilot was aware of the presence of. Just before the bridge, the pilot noticed the helicopter was slightly lower than intended to provide adequate clearance over the bridge. The pilot positioned the helicopter to pass over the bridge and then under the powerline.

The ATSB found the pilot lost awareness of the position of the powerline as he manoeuvred over the bridge, and nearby vegetation likely reduced the ability of the pilot to regain that awareness.

This accident provides another reminder of the dangers posed by powerlines during low-level spraying operations.

The powerline struck the centre of the helicopter’s front section just above its headlights and cut into the helicopter cabin and control instruments. The helicopter landed hard on the bank of the drain and was destroyed. The pilot escaped with minor injuries, and there was no post-impact fire. The helicopter had been fitted with a bladder-type fuel tank, and there was no indication of a fuel leak. The bladder-type fuel tank probably reduced the likelihood of a fuel leak and post-impact fire following the collision.

“This accident provides another reminder of the dangers posed by powerlines during low-level spraying operations,” said ATSB Director Transport Safety Dr Stuart Godley.

“As this accident highlights, there may be limits to the extent to which operators can mitigate the risk of wirestrike during repeated low-level operations near powerlines.”

The ATSB points pilots and operators to a booklet jointly produced with the Aerial Application Association of Australia (AAAA), 

, which contains numerous lessons learnt from wirestrike accidents for pilots and operators. The AAAA also recently launched their Powerline Safety Program(Opens in a new tab/window) which promotes the marking of powerlines by powerline network operators wherever it is requested by a pilot, aviation company or landholder.   

“Pilots and operators involved in low-level aerial spraying are also reminded that flight helmets are vital to reducing the risk of injury in the event of an accident,” Dr Godley said.

Read the final report: Wirestrike involving a Robinson R44, VH-ZWK, 20 km from Naracoorte, South Australia, on 13 March 2019

The ATSB investigation of the grounding of the Australian Border Force Cutter (ABFC) Roebuck Bay on Henry Reef has revealed underlying safety issues with the effectiveness of ECDIS type-specific training, ECDIS software updates and the use of a single point feature to represent relatively large physical features on electronic navigational charts.

While planning the passage from Saibai Island in the Torres Strait Islands archipelago to Lizard Island, south-east of Cape Melville, ABFC Roebuck Bay’s previously used passage plan was amended, with its route inadvertently plotted over Henry Reef. 

The ship’s electronic chart display and information system (ECDIS) identified the reef as a danger to the planned route, however, the crew did not identify the danger either visually or by using ECDIS. The vessel continued on the amended route and grounded on Henry Reef just after midnight. There were no reported injuries or oil pollution, but the vessel sustained substantial damage.

The ATSB found the crew’s ability to check the amended route was limited as their training was not effective in preparing them for the operational use of their on board ECDIS.

The ATSB‘s investigation highlights that the safe and effective use of ECDIS as the primary means of navigation depends on operators being thoroughly familiar with the operation, functionality, capabilities and limitations of the specific equipment in use on board their vessel.

“ECDIS type-specific training needs to be designed, delivered and undertaken so operators have the required knowledge to confidently operate ECDIS as intended by the manufacturer,” ATSB Chief Commissioner, Greg Hood said.  

The ATSB also found the vessel’s ECDIS was not updated to the latest International Hydrographic Organization (IHO) standards and lacked the enhanced safety features of a new presentation library of symbology.

The ATSB reminds regulators, manufacturers, hydrographic offices and other concerned parties that their ultimate goal must be to eliminate the significant risks with the use of ECDIS or at least reduce them to an acceptable level in terms of navigational safety.

“Like all on-board equipment, ECDIS needs to be maintained and compatible with the latest applicable standards,” Mr Hood said.  

 “With the recent introduction of ECDIS as the sole means of marine navigation and the replacement of paper charts, the grounding was an opportunity for the ATSB to explore any potential safety impact of ECDIS in a real-world operational environment.”

The investigation involved interviews with Australian Border Force officers, crew and shore staff and hydrographers from the Australian Hydrographic Service and the ECDIS manufacturer. Extensive ECDIS analysis was also carried out, as was various ECDIS simulations and testing.

“As a result of the investigation, the ATSB considers the use of point features in electronic navigational charts to represent areas of relatively significant size on the earth’s surface is likely to increase the risk of the hazard posed by such features being misinterpreted and potentially reduce the effectiveness of ECDIS safety checking functions,” Mr Hood said.

 “While this did not specifically contribute to the grounding of Roebuck Bay, the investigation has shown that the implementation of ECDIS has introduced some unintended risks to marine navigation.”

The ATSB recognises that ECDIS and electronic navigational charts are an essential tool for navigation with many safety benefits; however, operating crew need to be aware that navigating with ECDIS is fundamentally different from navigation with paper charts.

“By allowing operators to view and change an electronic navigational chart to a larger compilation scale, ECDIS can make single point features representing rocks, wrecks and other obstructions appear progressively smaller as the scale is changed, creating the impression it is clear of a ship’s route or further away than what it actually is,” Mr Hood said.

ECDIS is a complex software-based system and the ATSB acknowledges the many challenges faced in its design, manufacture, and operation to ensure navigational safety.

“The ATSB safety message from this investigation reminds regulators, manufacturers, hydrographic offices and other concerned parties that their ultimate goal must be to eliminate the significant risks with the use of ECDIS or at least reduce them to an acceptable level in terms of navigational safety,” Mr Hood said.

Read the final report: Grounding of ABFC Roebuck Bay, on Henry Reef, Queensland, on 30 September 2017

The derailment of a loaded coal train at a gravel level crossing west of Oakey, Queensland, shows the importance of an effective inspection and maintenance process for the approach roads and crossing surface at level crossings, a new ATSB investigation highlights.

On 21 July 2017, the underframe of a low-clearance heavy road vehicle very likely damaged both rails as it travelled over the private level crossing on the Western Line between Oakey and Jondaryan.

A member of the public saw the vehicle come to a sudden stop as it passed over the crossing, appearing to have “bottomed-out”. According to the witness, the driver exited the vehicle and inspected under the trailer, which was carrying a front-end loader, while it was stopped on the level crossing. The vehicle then continued on its journey.

Soon after, as the coal train approached the level crossing, the train driver noticed a ‘kink’ in both rails and attempted to stop the train.

The driver reported the lead locomotive shuddered as it passed over the crossing and he observed a number of wagons derailing as the train slowed. In all the train’s two locomotives and 18 coal wagons derailed, while there was damage to about 300 m of rail infrastructure.  

 “If rail infrastructure is damaged due to a road accident, it is vitally important that the driver responsible report the matter to the local police or the asset owner as soon as possible,” said ATSB Director Transport Safety Dr Stuart Godley.

“Rail infrastructure managers, who are responsible for the management of the rail corridor, need to ensure that approach roads and the crossing surface at level crossings are subject to regular and effective inspection and monitoring processes,” Dr Godley said.

“This is particularly relevant for level crossings with gravel-based road surfaces and inclined approach roads.”

Since the accident, track manager QR has installed a sealed asphalt surface on both sides of the level crossing. QR has also taken a series of actions to improve its inspection processes for level crossings.

Read the final report: Derailment of coal train, 8 km west of Oakey, Queensland, on 21 July 2017

A pilot was experiencing acute levels of fatigue before falling asleep during an early morning freight flight from Devonport to King Island, an ATSB investigation has confirmed

The Piper PA-31-350 aircraft had reached top of descent into King Island when the pilot, who was the only person on board, started to feel tired and quickly fell asleep. After several unsuccessful attempts by ATC and other pilots in the area to contact the pilot, he awoke and advised ATC operations were normal and that he was turning back to King Island.

While on autopilot the aircraft had overflown the island by approximately 78 km to the north-west.

The aircraft landed without further incident. However, after talking with the operator, the pilot then flew from King Island to Moorabbin to complete his shift.

The ATSB found that the pilot had been awake for about 24 hours and had been unable to sleep during a scheduled rest period before the incident flight. Analysis confirmed the pilot’s fatigue was at a level known to effect performance, while further analysis showed that even if the pilot had been able to sleep during his rest period he still would have been fatigued to a level known to affect performance.

In addition, the pilot had not modified his sleep pattern in preparation for the planned night shift, contributing to his fatigue.

The ATSB found that the pilot had been awake for about 24 hours and had been unable to sleep during a scheduled rest period before the incident flight.

“This investigation highlights the need for pilots to assess their level of fatigue before and during their flight,” said ATSB Executive Director, Transport Safety, Mr Nat Nagy.

“Before commencing night operations pilots are encouraged to modify their usual sleep routines to ensure they are adequately rested.”

The ATSB also calls on operators to consider the risks of allowing a pilot to continue operating directly after a fatigue-related incident without corrective management.

“Just as it is the pilot’s responsibility to use rest periods to get adequate sleep and to remove themselves from duty if they feel fatigued, it is also incumbent on operators to implement policies and create an organisational culture where flight crew can report fatigue and remove themselves from duty in a supportive environment,” Mr Nagy said.

Information on fatigue management is available from the Civil Aviation Safety Authority(Opens in a new tab/window) and ATSB websites.

Read the final report: Pilot incapacitation involving Piper PA-31, VH-TWU, near King Island, Tasmania, on 8 November 2018

A freight train tanker wagon derailment after an axle failure due to an overstress crack highlights the importance of inspection techniques that detect fatigue cracking prior to failure, an ATSB investigation has found.

The primary occurrence that initiated the investigation was the 28 September 2017 derailment of a freight tanker wagon near Kimburra, Queensland. The wagon was part of the 730 metre long train 9T90, which comprised two locomotives and 52 GATX freight tanker wagons with a consignment of about 1.67 million litres of sulphuric acid.

The train crew were initially unaware of the derailment as it had no noticeable effect on the performance of the train. After travelling approximately 1,300 metres, upon seeing sparks from the derailed wagon, the driver applied the brake to stop the train gradually. There were no injuries and only minor damage to the track and rolling stock. There was no spillage of the train’s consignment.

The ATSB also analysed a second derailment, on 15 August 2018, involving the same type of wagon, finding that both derailments were the result of axle failure.

During the ATSB’s investigation a review of past failures and defects identified that the axle type was susceptible to fatigue cracking due to relatively minor damage that was not reliably detected prior to failure.

Effective axle inspection techniques that detect cracking prior to failure are fundamental to rail safety.

Rail axles are designed to have an infinite life and axles with undetected fatigue cracks that propagate to failure will usually result in a derailment. Axles should be resilient to fatigue cracking from in-service damage, and the ATSB’s safety message from this investigation highlights that effective axle inspection techniques that detect cracking prior to failure are fundamental to rail safety.

Following the 15 August 2018 derailment, rolling stock operator Incitec Pivot Limited (IPL) proactively inspected their entire GATX wagon fleet. Those inspections detected 17 cracked axles, and they were removed from service. IPL has also increased the frequency of inspections for the axle type while it replaces them with an improved version.

However, the ATSB has issued a Safety Recommendation to Aurizon, the company which conducts the inspections, to address the lack of using standard test pieces for checking test equipment. The ATSB acknowledges that Aurizon have taken proactive safety action to address anomalies in their inspection procedures, but the use of standard test pieces is an integral part of the relevant Australian Standard.

As such, the ATSB considers it represents best practice.

Read the final report: Derailment of acid train 9T90, near Kimburra, Queensland, on 28 September 2017

The Australian Transport Safety Bureau (ATSB) reminds flight crews to remain alert and vigilant during taxiing, following an incident where a high workload situation probably led to an air traffic controller forgetting conflicting instructions had been issued.

During the 30 April 2018 incident, an Airbus A321 airliner was taxiing to the gate after landing at Melbourne Airport when the captain had to brake heavily to avoid a possible collision with a taxiing Boeing 737-800. Both aircraft had been given clearance by the surface movement controller in the control tower to proceed through the same taxiway intersection.

While the ATSB’s investigation found several factors had increased the workload of the surface movement controller, this occurrence highlights the importance of flight crews remaining alert and vigilant during all phases of their flight, including taxiing. Separation of taxiing aircraft is a joint pilot and controller responsibility, and the timely action taken by the captain of the Airbus helped to avoid a potential collision.

During the morning peak period, the surface movement controller, who was conducting on-the-job training with a trainee air traffic controller at the time, was in the process of handing over the position at the end of shift to a relieving controller.

... this occurrence highlights the importance of flight crews remaining alert and vigilant during all phases of their flight, including taxiing.

Additionally, taxiway maintenance work had resulted in some taxiway closures. While the works were not directly related to the clearances issued to the two aircraft involved in this occurrence, they did reduce the efficiency of controlling taxiing aircraft, thereby increasing the controller’s workload.

The ATSB’s investigation highlights how increased workload and distraction can reduce performance and increase errors. For air traffic controllers, using tools and practices that reduce reliance on memory and delaying handovers until lulls in activity can mitigate these effects.

Read the final report: Taxiing proximity event involving Airbus A321, VH-VWQ and Boeing 737, VH-VZB, Melbourne Airport, Victoria, on 30 April 2018

Some flying training organisations may be conducting incipient spin training in aircraft not approved for intentional spinning, an Australian Transport Safety Bureau (ATSB) investigation into a fatal training accident has found. Depending on the aircraft type, the manufacturer may not have specified whether that restriction applies to an incipient spin or only a developed spin.

A new Safety Advisory Notice issued by the ATSB advises flying training organisations using aircraft not approved for intentional spinning to clarify with aircraft manufacturers the extent to which the intentional entry into the early stages of a spin, including an incipient spin, spin is permissible.

The accident occurred on 26 September 2017, during a Recreational Pilot Licence practice flight test. The instructor and student took off from Archerfield Airport, south-west of Brisbane, Queensland, in a Diamond Aircraft DA40. Radar data showed the aircraft commenced a climb to about 4,500 ft with a reducing groundspeed, consistent with stall recovery training. The data then showed the aircraft’s flight path to be a near vertical descent with an average descent rate of about 6,000 feet per minute.

The aircraft collided with terrain, with the impact destroying the aircraft and fatally injuring the instructor and student.

The ATSB’s investigation found the instructor and the student were likely conducting advanced stall recovery training – a lesson which probably included intentionally initiating incipient spins (the early stage of a spin). The investigation also found that the instructor could not or did not prevent the aircraft from entering a developed spin from an incipient spin, for reasons that could not be established.

The aircraft manufacturer advised that the DA40’s limitation prohibiting intentional spins was intended to include incipient spins. However, the incipient spin manoeuvre was not defined and some operators considered that an incipient spin was not an intentional spin.

While the Civil Aviation Safety Authority (CASA) requires the demonstration of recovery from an incipient spin during flight tests, there is no clear and consistent definition of the point at which a manoeuvre becomes a spin – or incipient spin – for the purposes of flying training.

The investigation also identified incorrect incipient spin recovery guidance had been provided by CASA in its Flight Instructor Manual. The Authority says it will review its guidance material.

“The ATSB is calling for flying training organisations using aircraft not approved for intentional spinning to clarify with their aircraft manufacturer the extent to which the intentional entry into the early stages of a spin, including an incipient spin, is permissible and ensure that their aircraft are always operated in accordance with limitations,” ATSB Executive Director, Transport Safety Mr Nat Nagy said.

“Furthermore, operators should have procedures, and instructors should take all steps, to ensure that they maintain the necessary skills to avoid unintentional spins and recover from both incipient and developed spins.”

Read the Safety Advisory Notice AO‑2017‑096‑SAN-012: Is incipient spin training permitted in your aircraft?

Read the final report: Collision with terrain involving Diamond DA40, VH-MPM, 42 km west of Southport Aerodrome, Queensland, on 26 September 2017

For additional reading, the New Zealand Civil Aviation Authority booklet Spin Avoidance and Recovery(Opens in a new tab/window) provides valuable guidance for pilots in spin avoidance and recovery. The booklet provides the following advice for pilots regarding spin recovery:

To have a chance at recovery, the pilot must immediately recognise the spin, and its direction, know exactly what to do in the right order, and then execute the procedure correctly the first time.

The investigation into the in-flight break-up of a Cessna 210 near Albany, Western Australia highlights the need for operators and industry associations to make information available to pilots and employees about support services for problematic substance use.

On the morning of 24 October 2017, the owner-pilot of VH-DBU was observed at Albany Airport preparing the aircraft for the flight. A witness reported seeing the aircraft with its wheels chocked and engine operating, and the pilot outside of the cockpit. No one else was observed at the controls.   

After refuelling, the aircraft took off on a private flight to Bunbury with the pilot as the sole occupant on board.

It appeared that the pilot undertook some local flying before departing the Albany area. When about 30 km to the north-west of Albany a number of witnesses reported hearing, and in some cases seeing, the aircraft fly overhead. Witnesses recalled hearing a distinctive noise described as a sharp bang, crack of a whip, gunshot, or thunder and lightning. The aircraft was then seen in a steep descent until it disappeared out of sight, with smoke appearing shortly after indicating a post-impact fire.

The wreckage of the Cessna was located later that day dispersed over a wide area in the Mount Lindesay National Park, with the pilot found to be deceased.

The investigation found, for reasons that could not be established, abnormal operation of the aircraft produced high levels of unusual aerodynamic loading that exceeded the strength of the right wing and initiated an in-flight break-up and impact with terrain.

…the risks associated with continuing to operate with problematic substance use and the benefits of accessing help and support far outweigh the risks of a self-referral…

No pre-existing aircraft structural deficiency or damage, which could have contributed to the in-flight break-up, was found during the investigation. Local weather at the time was generally calm and clear.  

A postmortem of the pilot carried out at the direction of the coroner found no evidence of significant underlying medical issues. However, an accredited forensic science laboratory toxicological examination found the presence of methylamphetamine in the pilot’s system. The ATSB found that it increased the risk of operational misjudgements or mishandling due to impairment and involuntary action or inaction due to incapacitation, but this did not necessarily contribute to the accident.          

The ATSB’s safety message from this investigation is for operators and industry associations to consider how they can make information available to pilots and employees about support services for problematic substance use.

A self-referral for problematic substance use may be perceived as a threat to a pilot’s ongoing employment in aviation. However, the risks of continuing to operate with problematic substance use and the benefits of accessing help and support far outweigh any perceived risk of a self-referral.

Information for pilots should highlight that the Civil Aviation Safety Authority’s aviation medical framework allows pilots in stable remission to return to work. Information should include the increasing availability of employer and independent peer support organisations.

Further, the ATSB encourages pilots concerned about alcohol and drug use to visit the Human Intervention Motivation Study(Opens in a new tab/window) (HIMS) website. A cornerstone of HIMS is the understanding that substance dependence is a treatable medical condition, and is modelled on well-established overseas programs that have assisted thousands of pilots return to work.

Read the final report: In-flight break-up involving Cessna 210B, VH-DBU, 30 km north-west of Albany, Western Australia, on 24 October 2017