Multiple factors combined to result in an incident in which a container on a freight train collided with station infrastructure.

The ATSB’s investigation into the incident yielded important safety messages for rail infrastructure managers and maintainers, rail operators, and rail safety workers involved in the loading and examination of train services.

The incident occurred on 16 January 2018, as freight train 2BM9 passed through Maitland Railway Station at approximately 0748. The trailing edge of one of the containers on the train collided with the verandah gutter mounting brackets on Platform 1. Two lengths of the verandah gutter dropped to the surface of the platform. Although there were some people on the platform at the time, no one was in the immediate area of the collision, and no injuries were reported. 

The ATSB investigation found that, while the track owner had scheduled and undertaken clearance inspections at Maitland, these inspections had not detected that the increase in track height over time had reduced the available clearance and infringed on both the design measurements and track owner’s clearance specifications.

In addition to the increase in track height and clearance reduction, a loading irregularity on the train also existed at the time of the collision, where the container was not correctly secured to its wagon.

Ensure that processes and requirements are documented, understood, and adhered to.

The investigation found that the train operator had not documented its process for loading checks expected from the loading operations staff when securing containers to wagons.

The ATSB found these two elements combined to result in the collision between the freight train container and the verandah guttering at the Station.

This incident shows the importance of ensuring that processes and requirements are documented, understood, and adhered to.

Both the train operator and the rail infrastructure manager have taken proactive safety action to address the issues and reduce the likelihood of a recurrence.

Read the final report: Loading irregularity on train 2BM9, Maitland, New South Wales, on 16 January 2018

The accident occurred on 18 November 2016, when a Robinson R44 II helicopter was on a charter flight with one pilot and one passenger on board. About 41 km north-west of Mossman, Queensland, while flying above Mount Windsor National Park, the helicopter impacted dense rainforest after one of the main rotor blades struck and separated a section of the tailcone.

The helicopter broke-up into multiple fragments and descended through the forest canopy, and was subject to a post-impact fire.

The Australian Maritime Safety Authority’s Joint Rescue Coordination Centre detected a signal from the helicopter’s emergency locator transmitter (ELT), and the subsequent search and rescue operation was able to locate the wreckage and recover the seriously injured pilot. The passenger was fatally injured.

The activated transmitter led to the rescue of the pilot, who might otherwise have not survived.

The activation of the emergency location transmitter on impact resulted in the discovery of the accident site by the search and rescue helicopter about 1 hour and 48 minutes after initial detection of the ELT signal. The pilot may otherwise have not survived.

The ATSB investigation of the wreckage indicated there was low engine power and rotor speed at the time of the tail strike, which was likely the result of a main rotor blade stall event. The ATSB was unable to determine what precipitated the blade stall event.

The ATSB also found that the helicopter was likely operating in at least moderate turbulent flight conditions, which were not forecast.

It could not be determined if the wind and associated turbulence contributed to the accident, however it is important for pilots to consider the effect of the terrain on the weather forecast, which could result in a helicopter not achieving its predicted performance.

This accident highlights the importance of impact-activated ELTs, and the ATSB advocates for GPS encoded transmitters be used.

Read the final report: In-flight break-up involving a Robinson R44, VH-ZNZ, 41 km north-west of Mossman, Queensland, on 18 November 2016

The ATSB research report A review of the effectiveness of emergency locator transmitters in aviation accidents provides guidance to owners and operators on how they can maximise the reliability and effectiveness of emergency locator transmitters.

The ATSB is urging crewmembers to adhere to procedures that are created to keep them safe after a serious incident on a bulk carrier ship left two men seriously injured.

The ATSB has completed the investigation into how two crewmembers on board the bulk carrier Shanghai Spirit suffered serious injuries after a scaffolding tower fell.  

This serious incident occurred on 29 January 2017, when the 140 m geared bulk carrier was anchored in Keppel Bay, about 15 nautical miles north-east of Port Alma Queensland. Deck crewmembers were using a mobile scaffold tower to conduct painting and routine touch-up work in the cargo holds. As the scaffold tower was moved with two unsecured crewmembers still on the upper tiers, it became unbalanced and toppled forward onto the deck. 

On hitting the deck, the scaffold tower came apart and the two crewmembers were entangled in the components. Emergency services were notified of the incident, and a rescue helicopter was dispatched, making two trips out to the vessel to transport the men to hospital. Both men had to remain in hospital for several days before they could be released.

This is not the first such occurrence that the ATSB has investigated.

This serious incident highlights the importance of adhering to procedures that assure safety, as well as the value of effective supervision, with the investigation finding that, contrary to established procedures, two crewmembers remained on an unsecured scaffold tower when it was moved across the floor of a cargo hold.

As a result, the top-heavy and unstable scaffold tower toppled and fell. The crewmembers themselves were unsecured, without the required safety harness and lines.

This is not the first such occurrence that the ATSB has investigated. Similar occurrences in 2003 and 2009 also resulted in serious injuries and, in one instance, the death of a crew member.

Owners, operators and crewmembers are reminded to plan and undertake risk assessments for assigned tasks in order to identify any shortcomings in procedures and required risk-mitigation measures.

Read the final report: Fall from height and serious injuries to crewmembers on board Shanghai Spirit, near Port Alma, Queensland, on 29 January 2017

A fatal collision with terrain at a private airfield has highlighted the importance of obtaining all relevant information about local wind conditions before commencing an approach.

The accident occurred on 20 January 2018, when a Cessna 182 carrying a pilot and passenger was completing the journey from The Vale Airstrip to a private airfield at Tomahawk, Tasmania. The pilot conducted a number of orbits and then approached the runway.

The pilot was unaware, however, that his choice of approach direction exposed the aircraft to a tailwind that significantly increased the groundspeed on final approach. This resulted in insufficient landing distance. Additionally, the final approach was not stable. In combination with the tailwind, this resulted in the aircraft coming in too high and fast.

The aircraft touched down more than halfway along the runway – well beyond the runway threshold – and it bounced several times. In response, the pilot commenced a go-around, but the aircraft collided with a tree beyond the end of the runway, and it impacted the ground. The passenger was fatally injured, and the pilot sustained serious injuries. The aircraft was substantially damaged.

The investigation found that the pilot had not identified the direction of the local surface wind, although it was forecast. There was no windsock at the airfield, but there were a number of other means by which the pilot could have assessed the wind prior to commencing the approach.

If a safe landing cannot be assured, the pilot should abort the landing and go-around early.

ATSB Executive Director Transport Safety, Mr Nat Nagy said the investigation found that the selected landing direction meant that the aircraft had an increased tailwind and groundspeed on approach.

“The investigation also found that the final approach path was unstable,” Mr Nagy said. “What that meant was that the aircraft was both high and fast when it was coming into land which meant it landed well down the runway and bounced during that landing.”

The investigation also found that the go-around was initiated at a point from which there was insufficient distance remaining for the aircraft to climb above the tree at the end of the runway in the landing flap configuration and tailwind conditions.  

“The ATSB’s safety message out of this investigation is to remind all pilots that they should determine the local weather conditions, including wind direction and strength, prior to commencing an approach,” Mr Nagy said. “Most importantly, if a safe landing cannot be assured, the pilot should abort the landing and go-around early.”

Read the final report: Collision with terrain involving Cessna 182, VH-TSA, at Tomahawk, Tasmania, on 20 January 2018

The ATSB is reminding pilots, especially those involved in agricultural operations, to wear a correctly fitting helmet to reduce the risk of more serious head injury.

On 1 December 2017, the pilot of an M-18A Dromader aircraft was carrying out agricultural spray operations on a paddock north-west of the Emerald Airport in Queensland.

At about 0620, the aircraft was seen completing a spray run and commencing a turn to the right to line up for another spray run. About three quarters through the turn, the aircraft pitched down and the right wing collided with the ground. The aircraft flipped, and come to rest, inverted, facing in the opposite direction about 20-30 m from the initial contact point.

The pilot was able to exit the aircraft and the aircraft was substantially damaged. The ATSB was unable to determine the reason for the aircraft’s downward pitch during the turn. The pilot had no recollection of the accident and no mechanical issue was identified that may have contributed to the accident.

The pilot was wearing his personal flight helmet during the flight.

…pilots involved with agricultural operations are particularly vulnerable to accidents involving major or fatal head injury…

The ATSB found that the pilot’s personnel flight helmet struck the internals of the cockpit and based on the extent of damage to the helmet, it probably prevented the pilot receiving a more serious head injury.

The International Civil Aviation Organization circular Safety in aerial work Part 1. Agricultural Operations(Opens in a new tab/window) discusses the importance of wearing a correctly fitting flight helmet and highlights the pilots involved with agricultural operations are particularly vulnerable to accidents involving major or fatal head injury and the need for a helmet to be part of a pilot’s personal flying equipment.

Read the final report: Collision with terrain involving PZL Warszawa-Okecie M-18A Dromader, VH-WHR, near Emerald Airport, Queensland, on 1 December 2017

The ATSB is urging pilots to study all available weather information when preparing for a flight. This important safety message comes from the investigation into the hard landing of a balloon that left four people injured.

The accident occurred on 13 January 2018, when the International Balloon Flight Company was conducting scenic charter flights in the Hunter Valley, New South Wales, using four of the operator’s balloons. One of the balloons, a Kavanagh B-425 balloon registered VH-OKX, was operating with 15 passengers and one pilot on-board.

In preparation for the flight, the operator had reviewed several weather websites to obtain weather models for the intended flight. Bureau of Meteorology forecasts were reportedly reviewed, but as the forecasts were for the general area, the operator stated the he preferred local weather models for specific areas. He advised that he knew the upper winds were stronger but was confident with the weather model.

Shortly after take-off, the balloons experienced strong winds and turbulent conditions. As a result, the balloon deviated from its intended flight path and landing area.

The pilots of the four balloons communicated with each other regarding the wind speed and decided to land at the first suitable site. The predetermined landing areas were no longer available to them, as the wind change had taken them further east than they had planned. The area selected was a large open field that was not one of their normal landing areas.

The exposure of the pilots and passengers to hazardous weather conditions during the flight, and the injuries sustained during the landing, were avoidable.

The pilot of VH-OKX re-briefed the passengers for landing and advised them to rest their backs on the basket padding and hold onto the internal grab handles.

In light winds, the basket normally remains upright on landing. However, in winds greater than about 10 kt, layover landings can occur. During these landings, the basket tips onto its side and is dragged until the balloon envelope deflates. The baskets are designed to withstand these type of events and have padding and grab handles on the inside of the basket for occupant protection and support. 

Following this landing, the balloon changed direction slightly and was dragged about 40 m towards a large bush in the centre of the field. The side of the basket struck the bush, bouncing it forcefully back into the air. It subsequently came down on one corner and was dragged a further 50-60 m before coming to rest. Due to the significant ground impact forces, one passenger was seriously injured and three others sustained minor injuries.

The ATSB found that the exposure of the pilots and passengers to hazardous weather conditions during the flight, and the injuries sustained during the landing were avoidable and the use of the aviation-specific products generated by the Bureau of Meteorology would have clearly identified the presence of weather that was hazardous to balloon operations.  

Read the final report: Hard landing involving Kavanagh Balloon, B-425, VH-OKX, 4 km south of Greta, New South Wales, on 13 January 2018

The ATSB is reminding pilots of the limitations of the see-and-avoid principle, and encourages the use of airborne collision avoidance system (ACAS) technology after two Cessnas were involved in near collision south-west of Darwin Airport on 6 December 2017.

This serious incident occurred, when a Cessna 210 and a Cessna 206, both operating charter flights under Visual Flight Rules (VFR) from Darwin Airport to Port Keats departed in quick succession, and planned to track at 8,500 ft. Air traffic control had advised each pilot of the aircraft’s presence and plans.

The Cessna 210 was the trailing aircraft, but it was travelling faster than the C206. As the two aircraft converged, the pilot of the C210 lost sight of the other aircraft. With the wing structure obscuring the view, the pilot advised air traffic control but took no further action to ensure segregation between the aircraft as they drew nearer.

…the aircraft reportedly came within 5 metres of each other as they passed.

The situation culminated with the aircraft reportedly coming within 5 metres of each other as they passed. Owing to a combination of radar accuracy/resolution and the inaccuracy of the displayed height of the C210, the controller issued a safety alert only after the near collision had already occurred.

While see-and-avoid is the primary means of preventing collisions between VFR aircraft, the limitations of those techniques are well known. Recent advancement of airborne collision avoidance system technologies has made them viable for general aviation aircraft, and they should be considered. They provide valuable information to alert pilots of other aircraft in their proximity and can direct the pilot to take avoiding action, thereby reducing the risk of collision.

This report highlights an ongoing safety issue in aviation. Check out our research report, Limitations of the See-and-Avoid Principle, for more information on this important subject.

Read the final report: Near collision involving Cessna 210, VH-SYT and Cessna 206, VH-HPA, 46 km south-west of Darwin Airport, Northern Territory, on 6 December 2017

The ATSB’s investigation into the engine failure and forced landing of a Beech Aircraft 76 Duchess highlights the importance of correctly configuring a multi-engine aircraft following an engine failure.

The accident occurred on 1 June 2018, when the aircraft was conducting a private flight to Cessnock Airport, NSW, with a pilot and two passengers on board.

During the descent at night, the pilot felt the aircraft yaw toward the right and observed the right engine indications showing a loss of power. The pilot immediately commenced the engine failure checklist and configured the aircraft for single-engine flight. As part of that process, the pilot moved the propeller control to the feather position, but did not confirm that the right propeller had actually feathered. The aircraft could not maintain altitude and continued to descend, even after the pilot increased power on the left engine to maximum.

As the aircraft descended through about 5,500 ft, the pilot calculated it would not be able to clear the high terrain between its position and Cessnock. The pilot declared MAYDAY, and after advising air traffic control, elected to conduct a forced landing.

With no intercom-connected headsets to communicate with the passengers, the pilot did not attempt to warn them of the impending forced landing and focused on flying the aircraft.

The aircraft landed in a grassy field with the landing gear retracted. The pilot and passengers were not injured. However, the aircraft was substantially damaged.

The ATSB investigation found that, after the right engine failed, the propeller was not feathered, or did not feather. The increased drag of the unfeathered propeller prevented the aircraft from maintaining altitude, leading to the necessity of a forced landing.

The report highlights the importance of correctly configuring a multi-engine aircraft following an engine failure, and highlights the recurring safety concern of carburettor icing(Opens in a new tab/window).

The report also confirms the importance of conducting pre-flight passenger safety briefings. In this occurrence, the passengers were not briefed before the flight, nor were they warned about the impending forced landing.

Read the final report: Engine failure and forced landing of Beech Aircraft 76, VH-BDS, 49km north-west of Cessnock Airport, New South Wales, on 1 June 2018