The ATSB is urging owners and pilots of amateur-built aircraft to enhance their chances of avoiding a stall, after an accident at Parafield Airport in South Australia left an aircraft substantially damaged and the pilot dead.

The owner-pilot had built the Spitfire from a kit and operated it in the experimental airworthiness category. On 17 March 2013, he was participating in an antique and classic aircraft air display at Parafield Airport, South Australia. He performed a number of airborne passes above the runways in various directions and completed the display with a slow speed pass at 400 ft with the landing gear and some wing flap extended.

Towards the end of this pass, the pilot radioed the tower to coordinate a landing. He turned right then left and, soon after, a wing dropped, and the aircraft entered a steep descent. Some witnesses noticed a degree of spiralling before the aircraft descended out of sight. The aircraft crashed into a factory car park.

The ATSB is encouraging owner-pilots to consider the benefits of a stall warning device, preferably with aural output.

The ATSB found that while coordinating the landing clearance with air traffic control and flying a low-level circuit with a close downwind and base in turbulent conditions, the pilot inadvertently allowed the airspeed to decay. As it turned, the aircraft aerodynamically stalled, descended steeply, and impacted the ground. The aircraft was prone to aerodynamic stalling with little or no aerodynamic precursors, and it was not fitted with a stall warning device, increasing the risk of inadvertent stall.

Although amateur-built aircraft operated in the experimental category are not required to be fitted with a stall warning device (preferably with aural output), the ATSB is encouraging owner-pilots to consider the benefits of such devices as a last line of defence against stalling.

Pilots should also recognise that flying in an air display is different to normal operations and involves additional demands. Pilots who participate in air displays should consider these extra demands and, to the extent possible, ensure that the complete sequence, including landing, is planned and rehearsed.

Read the final report: Loss of control involving scale-replica Spitfire, VH-VSF, near Parafield Airport, South Australia, on 17 March 2013

Track workers take evasive action as an oncoming train unknowingly approaches their worksite.

The issue of safe work on rail in Australia continues to be a matter of serious concern for the ATSB after a ‘safeworking irregularity’ near Glenrowan resulted in a near miss between track workers and a V/Line passenger train.

The incident occurred on 29 October 2013, when the Australian Rail Track Corporation (ARTC) was undertaking ballast remediation and drainage maintenance on the bidirectional track between Benalla and Wangaratta, Victoria. The work was being done on the west track, but worksite protection was put in place on both the west and east tracks, with flagmen and Audible Track Warning signals (ATWs) placed either side of the worksite. The west track was designated ‘Absolute Occupation’, ensuring that no trains could use it, while ‘Track Force Protection’ was put on the east track, so that the workers would be made aware of any approaching train well before it arrived.

Safe work on rail continues to be a matter of serious concern for the ATSB.

The worksite at Glenrowan used two radio channels for communications. One channel was used for safety critical communication between the flagmen and the track force coordinator, the second was used for worksite communication between the track workers, including the track force coordinator. The track workers relied on the track force coordinator for safety critical communication since they had no direct communication with the flagmen.

At approximately 0730, V/Line passenger train 8610, travelling between Albury and Melbourne on the east track, stopped at Wangaratta to pick up passengers. The track force coordinator at Glenrowan was made aware of the train and instructed the flagmen to remove the ATWs and allow the train to pass the work site unrestricted. This was done without informing the work site supervisor or any of the track workers.

At about 0744, the outer flagman observed train 8610 and contacted the inner flagman to let her know that the train was approaching. The inner flagman attempted to contact the track force coordinator multiple times, but did not get a response. The track force coordinator was in conversation with the work site supervisor and not within earshot of either of his radios. The inner flagman then tried to alert the track force coordinator by whistle, but without success.

At about the same time, the work site supervisor observed train 8610 approaching and called out ‘Train on!’ on the work site radio.

The track workers also saw the train and took action to ensure that they and their machines were clear of the east track. The driver of Train 8610 did not notice anything unusual as the train passed through the worksite (without incident) at about 0746.

After the incident, the work site supervisor took control of the site. The track force coordinator was tested for the presence of alcohol or other drugs which proved negative.

As a result of this occurrence, the ARTC held a post-incident meeting with all relevant personnel to discuss the incident and reinforce the necessity to follow procedures when providing track protection. The program manager instructed all site personnel that ATWs were to be left on track to warn of trains approaching worksites.

The ARTC has also provided follow-up training and recertification regarding the relevant network safeworking rules.

The issue of safe work on rail in Australia is a major concern for the ATSB. The ATSB has investigated several accidents that have occurred when maintenance work was being carried out on or near railway tracks. The issue forms parts of the SafetyWatch initiative, which provides warnings and strategies to help transport workers keep themselves safer.

Read the final report: Safeworking irregularity, at Glenrowan, Victoria, on 29 October 2013

The ATSB is reminding pilots to recognise the implications of abnormal engine indications, after a helicopter lost power in mid-air.

On 13 November 2013, the pilot of a Robinson R22 helicopter was conducting aerial mustering on a property about 155 km SSW of Normanton, Queensland. The helicopter was hovering behind a mob of cattle when the pilot felt the helicopter jerking. He landed and conducted a magneto check (magnetos are a component of the ignition system). He selected the left magneto and the engine rapidly lost power. He then selected the right magneto and the engine ran normally. He reselected the magneto switch to ‘both’ and attempted to get in contact with the property manager.

This accident highlights the importance of understanding the implications of abnormal engine indications.

Unable to make contact with the manager, he elected to take off. Once airborne, he was able to communicate with the manager via the ultra-high frequency radio. He turned the helicopter towards a road and commenced an approach to land on the road. At about 20 ft above ground level, however, the engine stopped. The pilot lowered the collective and flared the helicopter for landing. On impact, the helicopter spun around 180º. The helicopter was substantially damaged, but the pilot was uninjured.

An engineering inspection of the left magneto revealed that the distributor bushing was loose, resulting in 6 mm of movement in the plastic gear wheel. As a result, the magneto was providing the ignition spark to an incorrect engine cylinder at the wrong time.

This accident highlights the importance of understanding the implications of abnormal engine indications.

The Robinson R22 Pilot Operating Handbook advises pilots that, when a magneto malfunction is suspected in-flight, select the magnetos to the BOTH position and land as soon as practical.

Read the final report: Total power loss involving a Robinson R22, VH-STK, 155 km south-south-west of Normanton Aerodrome, Queensland, on 13 November 2013

A collision between two aircraft has shown the dangers that exist at Australia’s many non-controlled aerodromes.

On 10 November 2013, a flight instructor and a student pilot were flying circuits in a Cessna 152 at Tyabb aerodrome, Victoria. Deciding to conduct a practice glide approach and a touch-and-go landing, the pilot commenced the approach from closer to the runway than for a normal circuit. As they commenced a continuous turn towards runway 17, he broadcast his intentions.

 At the same time, the pilot of a Jabiru J160 with one passenger on board was at the holding point, preparing to take off from the same runway. He heard the Cessna’s broadcast, but when he looked for it in the normal circuit position, he could not see it. He assumed that it was sufficiently distant that he would have time to leave the holding area and take off. He broadcast that he was lining up and rolling on runway 17, and then he commenced the take-off run.

This accident has demonstrated the need for pilots to maintain good communication and a good lookout, especially when operating at non-controlled aerodromes, and doubly so when conducting non-standard or modified circuits.

In fact, the Cessna was much closer than he thought, coming in behind him on a high, close final approach. The pilot of the Cessna had seen the Jabiru waiting at the holding point, and broadcast that he was coming into the runway. He assumed that the Jabiru would continue to hold until the Cessna had landed.

Neither pilot, however, heard the other’s broadcast and they may have transmitted their calls simultaneously.

The student pilot of the Cessna continued the glide approach, aiming to touch down about halfway along the runway. The Jabiru, however, had commenced take-off and, as his aircraft became airborne, the pilot saw the underside of the Cessna appear from above and fill the windscreen. The Cessna appeared to be overtaking the Jabiru very slowly and still descending.

The two aircraft collided, with the elevator trim tab of the Cessna contacting the fin of the Jabiru. The pilot of the Jabiru would later recall that the wheels of the Cessna appeared to be either side of his cockpit, with the front wheel just clear of the Jabiru’s propeller blades.

The pilot of the Jabiru forced the aircraft onto the ground and it skidded along the runway.

The pilot of the Cessna heard a loud bang behind him, but did not see the Jabiru. He took control of the aircraft from the student and commenced a go-around.

The Jabiru was substantially damaged, and the Cessna sustained damage to the right elevator and trim tab. No one was injured.

This accident has demonstrated the need for pilots to maintain good communication and a good lookout, especially when operating at non-controlled aerodromes, and doubly so when conducting non-standard or modified circuits.

The issue of safety around non-controlled aerodromes is one of the ATSB’s top safety concerns. ATSB research has found that, between 2003 and 2008, there were 709 airspace-related events at, or in the vicinity of non-towered aerodromes. This included 60 serious incidents and six accidents (mid-air and ground collisions). Most of the 60 serious incidents were near mid-air collisions.

The ATSB’s SafetyWatch initiative and report on safety in the vicinity of non-towered aerodromes, provides useful advice and strategies for pilots.  

Read the final report: Mid-air collision involving a Cessna 152, VH-TNV, and a Jabiru J160, 19-4430, Tyabb Airport, Victoria, on 10 November 2013

The collision between the bulk carrier Furness Melbourne and the yacht Riga II on 26 May 2012 near Bowen, Queensland emphasises the need for those navigating vessels of all types and sizes to keep a proper lookout and take early and appropriate action to avoid a collision.

Riga II was dismasted and its hull was damaged, but no one was seriously injured. The yacht was towed to Bowen by a volunteer marine rescue vessel. Furness Melbourne was not damaged and after rendering assistance, continued its voyage.

The ATSB found that a proper lookout was not being kept on either vessel in the time leading up to the collision. Furness Melbourne’s lookout had sighted Riga II’s starboard sidelight prior to the collision, however, the officer of the watch made a series of assumptions based on limited information and concluded that the light was from a distant navigation buoy rather than a vessel that represented a risk of collision.

The ATSB found that a proper lookout was not being kept on either vessel in the time leading up to the collision.

Riga II’s watchkeeper did not visually identify Furness Melbourne’s navigation lights in time to make an effective appraisal of the situation, did not set the yacht’s automatic identification system (AIS) unit on a range scale that would provide adequate warning of approaching vessels, and when alerted of the approaching ship, misinterpreted the information.  

The ATSB has investigated 39 of the reported 60 collisions that have involved ships and small vessels over the past 25 years. The findings of these investigations invariably include the failure of watchkeepers to keep a proper lookout.

Read the final report: Collision between the bulk carrier Furness Melbourne and the private yacht Riga II, north of Bowen, Queensland, on 26 May 2012

On 22 January 2013 the pilot of a Cessna U206F amphibious aircraft was conducting a joy flight over Corio Bay in Victoria with two passengers on board. During the flight the pilot landed to refuel at Barwon Heads Airport, requiring the use of the landing wheels.  When departing from Barwon Heads the pilot became distracted and did not retract the landing wheels during the after take-off checks.

On the return trip the pilot diverted for sightseeing before heading back to Corio Bay for a water landing. Under perceived time pressure, the pilot did not complete the normal downwind and short final checks, and failed to notice that the wheels were still extended. On touchdown the aircraft pitched over and came to rest upside down. The pilot assisted the passengers to safely evacuate the aircraft before rescue vessels arrived. No one was injured in the accident.

This accident highlights the importance of following procedures and diligently completing checklists.

This accident is a reminder that human error can occur at any time and highlights the importance of managing operational pressures and avoiding distractions. It also highlights the importance of following procedures and diligently completing checklists. Effective application of threat and error and distraction management principles can reduce risk. The ATSB noted that the operator’s requirement for the passengers to wear life jackets throughout the flight enhanced the survivability of the passengers.

Read the final report: Wheels-down water landing involving Cessna U206F floatplane, VH-UBI, Corio Bay, Victoria, on 22 January 2013

The risks associated with the handling of an approach to land have been highlighted by the ATSB after a Dash 8’s approach set off its warning system.

The incident occurred on 17 May 2012, when the flight crew of the Dash 8 was conducting a circling approach to Laverton Aerodrome in Western Australia. It departed from Perth as a passenger charter flight, with a flight crew composed of a captain and a first officer. As the crew commenced descent into Laverton, they observed that the weather in the area was mostly clear but there were bands of fog and low stratus cloud in the general vicinity of the aerodrome.

Because of the low cloud, the crew positioned the aircraft to maintain their visual reference with the runway threshold and conducted a circling approach. The resulting final approach, however, required such a high rate of descent that it triggered the aircraft’s Enhanced Ground Proximity Warning System (EGPWS). The crew heard some alerts from the EGPWS and knew they had a high rate of descent, but they did not identify an unstable approach.

...the flight crew did not have an adequate understanding of the aircraft’s EGPWS or the operator’s standard operating procedures in regard to mandatory go-arounds.

The stability of an aircraft’s final approach is an extremely important safety element. As they draw nearer to the runway, pilots need to ensure that their approach fulfils various requirements to achieve a stabilised approach. That includes being on the correct flight path to the runway touchdown point at the correct speed and with the aircraft in the landing configuration. The power setting needs to be appropriate for the aircraft configuration and the rate of descent less than 1,000 ft/min.

“If any of these requirements are not met,” says Dr Stuart Godley, head of the ATSB’s research section, “it constitutes an ‘unstable approach.’ Pilots in that situation should undertake a go-around, and try the approach again. The consequences of not doing so can be severe.” The Flight Safety Foundation cites a lack of go-arounds from unstable approaches as the number one risk factor in approach and landing accidents and the primary cause of runway excursions.

Despite the activation of the EGPWS, the flight crew of the Dash 8 continued their approach and landed safely.

The ATSB investigation found that at the time of the occurrence, the flight crew did not have an adequate understanding of the aircraft’s EGPWS or the operator’s standard operating procedures in regard to mandatory go-arounds.

In response to this occurrence, the operator refined their stabilised approach criteria and formulated a method of incorporating realistic EGPWS warning events in the Dash 8 simulator training program. This incident highlights the importance of crews adhering to standard operating procedures and correctly responding to cockpit warnings.

The issue of handling approaches to land is one of the ATSB’s safety priorities, and it forms part of the SafetyWatch web initiative.

Read the final report: Unstable approach involving de Havilland Canada Dash 8, VH-XFZ, Laverton Aerodrome, Western Australia, on 17 May 2012

The ATSB has identified issues with fatigue management after a train passed three signals without taking any action.

The incident occurred at about 0229 on 30 January 2013, when a work crew was picking up litter on the track at Hurlstone Park. They had arranged for Absolute Signal Blocking (ASB)—a protection measure in which the area controller sets signals at ‘stop’ to prevent rail traffic from entering the affected section. The stop signals are preceded by signals set to ‘caution’, so as to give train drivers enough time to brake and come to a stop at the signal.

At that time, Pacific National freight train 9837 was travelling from Nowra to Orange, crewed by a trainee driver and a more senior co-driver. As the train reached the area of Marrickville, it passed a caution signal but the brakes were not applied as required. Forty seconds later, it passed through a stop signal.

...the ATSB investigation found that the more senior co-driver had inadvertently fallen asleep during the approach to the signals.

Immediately, a visible alert appeared and an alarm sounded at Sydenham signal complex. The area controller broadcast an emergency message ‘9837, stop, stop, stop!’ over the open channel radio to attract the attention of the crew of the train. There was no response. Ten seconds later, the area controller again broadcast the same message, and again there was no response from the train crew.

Meanwhile the work crew picking up litter on the track heard a warning from their lookouts that there was a train coming towards them on the Down Goods line. At this point the train was approximately 300 m away from them. The two members of the work crew on track moved to a safe area behind the platform.

Just before the train passed another stop signal the driver reduced the throttle from power to idle and, shortly after passing the signal, he applied the brakes, bringing the train to a stop.

There had been no injuries or damage, but the ATSB investigation found that the more senior co-driver had inadvertently fallen asleep during the approach to the signals. The trainee driver, in a reduced state of alertness, missed the first signal at caution, and the next signal at stop. He applied the brakes once the train passed the final signal at stop after realising this signal applied to his train.

A number of Pacific National’s policies and procedures were examined to determine if any area of the management or training of the train crew contributed to the incident. Fatigue management, and in particular, over- reliance on the use of bio-mathematical model scores used to roster train crew, was one area where improvement was needed. The ATSB also found that there was an absence of adequate procedures and training for drivers who were performing co-driving duties while coaching trainee drivers.

As a result of the incident Pacific National has undertaken a range of actions to improve its approach to fatigue management and the implementation of fatigue training. They have also commenced a review of ‘signals passed at danger’ risk management processes and training requirements for coach/tutor drivers. A trial has commenced of improved data loggers for the Bulk Rail fleet.

Read the final report: Multiple SPAD by freight train 9837, at Hurlstone Park, New South Wales, on 30 January 2013

On 23 July 2013, a Bell 47G2A helicopter flying on a local photography flight from Lake Manchester, Queensland sustained a total power loss. The pilot conducted an auto-rotation which resulted in a heavy landing, causing substantial damage to the helicopter.

The pilot had taken off from Lake Manchester with the carburettor heat on, as was required for the climb. The pilot also adjusted the carburettor heat as required according to the gauge. At the time of the accident the temperature was 13.5 ˚C and the dew point was 9.1 ˚C. According to the carburettor icing probability chart, these conditions were conducive to carburettor icing.   

When the insurance assessor arrived following the accident, the helicopter was started and performed without fault. No fuel contamination was found and the helicopter was found to have been well maintained and in excellent condition. The insurance assessor considered that the weather conditions may have caused icing of the carburettor. The pilot reported that he would have expected the engine to run roughly if icing was present.

All pilots of aircraft fitted with a carburettor are advised to check weather forecast conditions and know the risk of carburettor icing before each flight. The carburettor icing probability chart is available from the CASA website. The report contains details of other helpful publications on carburettor icing.

Read the final report: Total power loss involving a Bell 47G2A, VH-KHJ, 11 km east of Amberley Airport, Queensland, on 23 July 2013