The ATSB’s final report into the wirestrike and collision with terrain of a Cessna 172RG at Parafield Airport, South Australia, is an important reminder for pilots to fly in a controlled manner to increase the likelihood of a successful forced landing.

On 3 July 2018, the Cessna VH-LCZ was on its final descent for landing. As the aircraft passed through 450 ft, its propeller speed reduced to 1,300 rpm. The pilot turned on the carburettor heat and switched the fuel tank selection from BOTH to LEFT. However, the engine did not respond.

Realising that the aircraft could not maintain enough altitude to reach the runway, the pilot started preparing for a forced landing. The pilot turned towards an unlit area ahead of the aircraft, which he thought was an open space, and pitched the nose of the aircraft down to achieve the optimum glide speed.

As he descended, the pilot heard the sounds of the fuselage striking treetops. The aircraft’s nose wheel then struck a power line and it collided with terrain. The pilot received minor injuries.

The ATSB found that the lack of application of carburettor heat throughout the flight, in conjunction with the weather conditions, which were conducive to severe carburettor icing at descent power, made it likely that the engine failed due to carburettor icing.

When faced with conducting a forced landing, flying in a controlled manner-that is wings level and the aircraft positioned to achieve the optimum glide speed- can improve your chances of surviving a forced landing.

The ATSB reminds pilots to maintain awareness of the weather conditions that are conducive to carburettor ice formation and to closely monitor their aircraft performance during times when the risk exists.

When faced with conducting a forced landing, flying in a controlled manner – wings level and the aircraft positioned to achieve the optimum glide speed – can improve the chances of surviving a forced landing.

The Civil Aviation Safety Authority’s carburettor icing probability chart(Opens in a new tab/window) is a useful tool to help determine your icing risk.

Read the final report: Wirestrike and collision with terrain involving Cessna 172RG, VH-LCZ, Parafield Airport, South Australia, on 3 July 2018

The ATSB is reminding freight operators of the need to ensure train drivers receive regular training and competency assessments on how to operate on steep continuous gradient rail routes.

On 22 April 2017, a Qube Logistics grain train was travelling from Bogan Gate to Port Kembla, NSW. During its descent down Illawarra Mountain—one of the steepest descents in the NSW rail network— the driver realised control was lost and advised network control that the train was running away..

The ARTC network controller with the Sydney Train’s controller ensured the train had the ‘full road’ with no rail traffic in its path. Reaching a maximum speed of 107km/h as it rounded a curve approaching Unanderra Station, the train came to a stop once it reached the rising gradient at the Unanderra North Junction.

The ATSB found the methods used to control the train during the descent were not in line with the train handling procedures.

Ten brake applications were made as the train descended the mountain between Dombarton and Unanderra. However, the use of multiple brake applications to try and control the train meant the pneumatic braking system was unable to fully recharge between applications reducing its braking capability. Control over the train was further reduced when its dynamic braking system was rendered inoperative.

The ATSB also found actual mass of the train was 10 per cent heavier than recorded. It is likely that the additional weight placed an extra load on the braking system and affected the handling characteristics of the train.

The incident highlights the need for freight operators to ensure regular training and competency checks of train crews who operate on steep descents. Contingency plans and procedures for the management of runways in this area should be continually reviewed and tested by rail infrastructure managers.

Read the final report: Runaway of grain train 8960, Dombarton to Unanderra, New South Wales, on 22 April 2017

The ATSB is highlighting the importance of the early detection and treatment of defects of rail infrastructure, especially those that could cause a rail facture and lead to derailment.

The ATSB’s investigation into the derailment of freight train 1501S, near Dry Creek in South Australia on 28 July 2017, found a vertical split head defect had developed through the centre line of the lower leg rail in the curve approaching Dry Creek South.

The ATSB determined the defect had developed undetected from impurities in the rail during its manufacture. When a preceding train travelled over the defect, it caused a break in the rail that was not obvious – visually – to the crew of the following train 1501S. When 1501S travelled over the break, a 2-metre section of rail fragmented derailing its last three wagons.

Acting ATSB Executive Director Transport Safety, Patrick Hornby said the defect in the rail failed to be detected, despite the previous month’s ultrasonic track inspection.

No follow-up action was triggered by the testing provider as required by the track owner creating a missed opportunity for the detection and possible treatment of a defect

“ATSB investigators found that ultrasonic testing indicated the presence of an anomaly, however these results were attributed to the rail’s poor surface condition and not a potential rail defect,” Mr Hornby said.

“No follow-up action was triggered by the testing provider as required by the track owner, creating a missed opportunity for the detection and possible treatment of the defect.”  

Following the incident, the testing provider reviewed its operational and reporting procedures and the rail owner confirmed the effectiveness of its code of practice for ultrasonic rail testing.

“This incident highlights the importance of maintenance providers reporting testing anomalies, to highlight operational risk and to initiate further action,” Mr Hornby said.

Read the final report: Derailment of freight train 1501S, near Dry Creek, South Australia, on 28 July 2017

The ATSB recommends hot-air balloon operators, following their pre-flight safety briefing, have passengers demonstrate the landing position in the basket, to ensure there is no confusion about what to do in an emergency.

On 8 February 2018, a Kavanagh B-350 hot-air balloon, registration VH-EUA, operated as a scenic charter flight north of the Yarra Valley in Victoria with one pilot and 15 passengers on board.

About 45 minutes into the flight, the balloon encountered a sudden wind change with associated turbulence. The turbulence initially caused the balloon to increase altitude but then it began to descend. The pilot decided to conduct an emergency landing in a nearby paddock. Eleven passengers were injured in the resulting hard landing, with four requiring hospitalisation.

Acting ATSB Executive Director Transport Safety, Mr Patrick Hornby said that despite a pre-flight safety briefing, there was confusion among the passengers about what to do when the pilot advised them to get into their landing position.

It is good practice to ensure that all passengers know what they need to do after they have boarded the basket, including what they need to do in an emergency situation.

“The accident happened when the balloon encountered an unexpected wind change,” Mr Hornby said. An emergency landing was conducted, and some of the passengers were confused about what to do.”

The use and availability of Illustrated safety information cards is also recommended, particularly for passengers from a non-English speaking background. These should be kept or displayed in a convenient location for passengers to access or refer to.

“There are some important safety lessons from this accident,” Mr Hornby said. “It is good practice to ensure that all passengers know what they need to do after they have boarded the basket, including what they need to do in an emergency situation. Passengers need reminders.”

On 10 October 2018, the Civil Aviation Safety Authority released a cabin safety bulletin (Cabin safety bulletin 12 - General aviation passenger briefings(Opens in a new tab/window)) to provide guidance on how to conduct an effective safety briefing to improve passenger situational awareness and their response during an emergency.

Read the final report: Hard landing involving Kavanagh B-350 hot-air balloon, VH-EUA, 6 km east-north-east of Yarra Glen, Victoria, on 8 February 2018

The ATSB is urging flight crews to stop and seek further guidance when confronted with any ambiguous situations pre-flight.

The ATSB’s investigation into an incident involving a passenger flight brings an important warning for crews about the potential for anomalies in warning systems.

The incident occurred on 26 May 2018, when a SAAB 340B was taxiing at Esperance Airport, Western Australia. The aircraft was scheduled to conduct a passenger flight to Perth with three crewmembers and 32 passengers on board.

As the aircraft taxied, the first officer (FO) conducted a test of the ice protection system, and the flight crew received a Master Caution. The warnings did not match any of the scenarios in the Quick Reference Handbook (QRH) checklist. The Captain discussed the warnings with the FO, how had not detected any defects in the de-icing system during the daily walk-around check of the aircraft.

The flight crew concluded that the warnings were most likely the result of a faulty sensor and there was no risk to the safety of the flight. They noted that the forecast freezing level was 7,500 ft and if necessary, the flight to Perth could be conducted as low as 4,000 ft. They elected to proceed with the flight as scheduled and the flight was conducted without further incident.

… if confronted with an abnormal or ambiguous situation pre-flight, which have the potential to affect safety of flight, crews should stop and seek further guidance.

After landing, the flight crew found a tear in the right stabiliser boot.

The ATSB investigation found that the crew had likely conducted the flight with a small defect in the boot, which increased in size during the flight. The reason for the ambiguous nature of the warnings could not be determined.

The incident highlights an important warning for flight crews regarding the potential for anomalies to occur in the operation of warning systems. In the event that fault indications are ambiguous and there is the possibility of affecting the safety of the flight, it is important to take the necessary, conservative precautions to resolve the issue prior to conducting the flight.

Damaged de-icing boot

Read the final report: De-icing boot failure involving Saab 340, VH-ZLH, Esperance Airport, Western Australia, on 26 May 2018

The Australian Transport Safety Bureau’s (ATSB) investigation into the in-flight propeller loss involving a Saab 340B was the result of a fracture of the propeller shaft on the right engine propeller gearbox (PGB).

The right propeller separated from the aircraft, with 16 passengers and three crew on board, while it was on approach to Sydney Airport from the south-west on 17 March 2017.

The ATSB found the fracture was due to a fatigue crack that originated in a propeller shaft flange dowel hole and spread through the shaft until it could no longer transmit the loads required to maintain the propeller on the aircraft.

The NSW Police Aviation Support Branch undertook a search operation for the propeller four days later. The propeller was located in dense bushland at Revesby, and airlifted out.

ATSB Chief Commissioner Greg Hood said the investigation was unable to determine, conclusively, what caused the fatigue crack to occur.    

“This was an extremely rare event, and the crew should be commended.”

“The ATSB’s investigation found the crew demonstrated a high level of professionalism in their communication, coordination and application of the safety checklist procedures in their response to the incident, which resulted in an uneventful single-engine landing at the airport,” Mr Hood said.

“This was an extremely rare event, and the crew should be commended.”

Following the incident, the engine manufacturer, General Electric, and the airline, undertook a number of proactive safety actions.

“The airline and the engine’s manufacturer have undertaken a number of proactive safety actions, such as the release of new service bulletins and airworthiness directives, and changes to their maintenance regime, to reduce the risk of this extremely rare event from occurring again,” Mr Hood said.

“Flying remains as one of the safest forms of travel for the public. Here in Australia, we have one of the best aviation safety records in the world.”

Read the final report: In-flight loss of propeller involving Saab 340B, VH-NRX, 19 km (10 NM) south-west of Sydney Airport, New South Wales, on 17 March 2017

The Australian Transport Safety Bureau’s (ATSB) final report into the loss of control and collision with terrain involving Beechcraft B200 King Air, registered VH-ZCR, highlights the importance of following a cockpit checklist.

During take-off from Essendon Airport, Victoria, on the morning of 21 February 2017, the aircraft diverged to the left of the runway centreline.

Having reached a maximum altitude of 160 feet (49 metres) above ground level, the aircraft began to descend with an increasing left sideslip. The aircraft subsequently collided with the roof of a building in the Bulla Road Precinct Retail Outlet Centre of Essendon Airport.

The aircraft was destroyed by the impact. The pilot and four passengers were fatally injured. Two people on the ground received minor injuries.

The ATSB’s investigation found that the pilot did not detect that the aircraft’s rudder trim was in the full nose-left position prior to take-off. The position of the rudder trim, which assists a pilot with controlling an aircraft’s movement around the vertical axis, resulted in a loss of directional control and had a significant impact on the aircraft’s climb performance.

ATSB Chief Commissioner, Mr Greg Hood said this accident emphasised the importance of having a cockpit checklist in place applicable to an aircraft’s specific and current modification status.

“Checklists are a part of every pilot’s pre-flight risk management plan and are an essential tool for overcoming limitations of the human memory,” Chief Commissioner Hood said.

“Checklists ensure action items are completed in sequence and without omission. In this particular tragic accident there were opportunities in the checklist that existed for the pilot to ensure the rudder trim was set to neutral prior to take-off.”

In addition to the importance of using a checklist, this accident also emphasises the challenges associated with decision-making during critical stages of a flight.

“Pilots need to carefully consider their decision-making, particularly during critical phases of flight, such as take-off,” Chief Commissioner Hood said.

Read the final report: Loss of control and collision with terrain involving B200 King Air, VH-ZCR, at Essendon Airport, Victoria, on 21 February 2017

Video: ATSB investigation highlights the importance of using a checklist

Click the image to link to view YouTube video

The Australian Transport Safety Bureau (ATSB) has made available on its website the complete library of the iconic aviation safety publication – the Aviation Safety Digest.

The 150 editions of the famed ‘crash comic’ span from 1953 to 1991, and include special editions on human factors, agricultural operations, visual flight and wake turbulence – to name just a few.

Speaking at the Civil Aviation Historical Society’s Airways Museum at Essendon Airport to officially launch the online editions, ATSB Chief Commissioner Greg Hood said this remarkable collection now preserves such an important part of Australia’s aviation safety history.

“Produced by our predecessor over 38 years, the Aviation Safety Digest provided valuable information and advice to help promote aviation safety in Australia,” Mr Hood said. “Australia has been at the forefront of transport safety for many years. It is important that we preserve and display our history, and this online library is an important historical record of aviation safety in the country.”

Chief Commissioner Hood personally thanked Ross Robotham, who scanned every page of each issue, and Research Fellow at the Civil Aviation Historical Society, Dr Peter Hobbins, who made the issues searchable.

“Without the diligence of Ross and Peter, it would have been impossible make this valuable aviation safety resource publicly available,” Mr Hood said,

“Making the collection of the Aviation Safety Digest available online is a wonderful example of the collegiate nature of Australian aviation.”

Esma Job, widow of Macarthur Job, who was the first full-time editor of the digest, said she was thrilled to see her late husband's work preserved online for everyone to see, now and in the future. 'Mac', as he was known, authored 64 issues of the digest over 14 years.

The online library of the Aviation Safety Digest is available on the ATSB website..

Read about the history of the Aviation Safety Digest on the Civil Aviation Historical Society and Airways Museum's website: 

The ATSB is urging pilots to ensure they use effective see-and-avoid techniques to avoid traffic conflicts when flying at non-towered aerodromes.

The ATSB’s investigation into a traffic conflict between a Robinson R22 and a Cessna C208 highlights the importance of pilots maintaining a constant visual lookout to avoid traffic conflicts.

On 19 September 2017, a Cessna C208 (VH-SJJ) and a Robinson R22 (VH-MFH) came into traffic conflict at the Ballina Bryon Gateway Airport. The Cessna entered and rolled on runway 06 while the Robinson was on its short final at 200 ft about two thirds along the same runway.

The ATSB found that despite the use of the common traffic advisory frequency (CTAF) and the certified air/ground radio service (CA/GRO) to advise of their positions by both pilots and instructor on board VH-MFH (MFH was on a training circuit) the pilot of VH-SJJ moved onto the runway before he had visually identified the helicopter.

Traffic conflicts are among the most common occurrences at non-towered aerodromes.

ATSB Executive Director, Transport Safety, Mr Nat Nagy says that traffic conflicts are among the most common occurrences at non-towered aerodromes.

“The proper use of the CTAF and the CA/GRO are important tools to build your situational and traffic awareness, but it is also important to maintain a constant visual lookout to confirm the information you are receiving.”

“There are high workloads while flying in and around airports. Things can change quickly, updates on what is happening can take time to reach a pilot, or they can be misheard or not heard at all.

“Maintaining constant visual awareness is a vital technique to ensure you are able to operate safely,” Mr Nagy said. 

Read the final report: Traffic conflict involving Cessna 208, VH-SJJ and Robinson R22, VH-MFH, at Ballina Byron Gateway Airport, New South Wales, on 19 September 2017

Additional reading: A pilot's guide to staying safe in the vicinity of non-controlled aerodromes.

The ATSB is highlighting the need for a shared understanding or ‘shared mental model’ of a ship’s passage plan by bridge crew and harbour pilots to ensure a safe voyage.

The ATSB’s investigation into the near grounding of the bulk carrier Aquadiva in Newcastle Harbour on 12 February 2017 also underlines the importance of a ship’s bridge crew and harbour pilot engaging in effective communication and information exchange to develop this shared understanding or mental model of a ship’s passage plan.

During the investigation, the ATSB found that Aquadiva’s bridge crew had not received the harbour pilot’s passage plan before he boarded. This meant the harbour pilot and the bridge crew were operating with a different set of assumptions for what constituted a safe passage.  

This misunderstanding restricted the ability of the crew to monitor the ship’s progress properly and identify or correct any errors in the ship’s progress.

A shared understanding or mental model of a ship’s passage lets the harbour pilot and bridge crew work together to identify errors and take steps to correct them quickly.

As a result, when insufficient rudder was applied during the ship’s passage through a section of the harbour known as The Horse Show, the bridge crew did not identify the issue or alert the harbour pilot. The ship then slewed, or moved sideways, toward the southern edge of the channel, and went over the limits of the marked navigation channel.

Once the issue was identified, additional tugs were required to arrest the ship’s movement and return it to the channel to complete its safe passage out to sea.

ATSB Executive Director, Transport Safety, Mr Nat Nagy, said a shared understanding or mental model of a ship’s passage lets the harbour pilot and bridge crew work together to identify errors and take steps to correct them quickly.

“This shared understanding can be enhanced through tools such as a portable pilotage unit,” Mr Nagy said.

“In this case it could have helped with the communication between the pilot and bridge crew to point out and clarify the differences between each passage plan.”

Read the final report: Near grounding of Aquadiva, Newcastle Harbour, New South Wales, on 12 February 2017