The continuing problem of road users failing to yield to trains at level crossings has been highlighted in the ATSB’s latest investigation into the fatal 2012 accident near Port Germein in South Australia.

The accident occurred on 19 March at the Port Flinders Causeway Road level crossing. A Pacific National ore train was travelling on the interstate main line between Port Augusta and Port Pirie. As the train drew closer to the level crossing, it slowed for a temporary speed restriction of 50 km/h. About 200 m from the level crossing, the train driver saw two motor vehicles travelling towards the crossing. He immediately sounded the train’s horn.

The first car, a yellow Hyundai Accent, appeared to be slowing; the train driver sounded the horn a second time just as the vehicle disappeared from his view behind some thick vegetation. As the car re-emerged from behind the vegetation, it looked as if it would stop at the crossing. The train driver sounded the horn a third time, continuously. However, the car continued and entered the level crossing into the path of the train. The train driver made an emergency brake application, but given the train’s closeness to the level crossing and its relative size and weight, it was unable to stop before colliding with the car.

Although they vaguely recalled hearing a horn, they did not relate this to the
approaching train...

The front of the train struck the passenger side of the motor vehicle and then continued to travel around 256 m past the level crossing. The car’s passenger died in the accident and the driver sustained serious injuries. The locomotive crew were shaken but not hurt. The motor vehicle was severely damaged, the train received minor damage. There was little damage to the track and fixed infrastructure.

The driver of the motor vehicle was a local resident and had regularly traversed the level crossing. Although they vaguely recalled hearing a horn, they did not relate this to the approaching train and could recollect little else regarding events prior to the accident.

The level crossing was controlled by passive approach warning signs and a ‘Stop’ sign at the crossing. These required a road user to stop the vehicle at the ‘Stop’ sign and detect the presence of any train through direct visual observation.

The ATSB concluded that the motorist’s attention may have been diverted during a critical period when they would normally have stopped to look for a train.

The ATSB urges all drivers of motor vehicles to be vigilant and obey road traffic signage, especially at level crossings where accidents can easily result in fatalities, serious injuries and extensive damage to infrastructure.

Read the final report: Collision involving a motor vehicle and train 4460S, 10 km south of Port Germein, South Australia, on 19 March 2012

On 9 December 2012 the pilot of a Robinson R22 helicopter took off from a fishing camp at the mouth of the Normandy River in Queensland on a private flight.

The pilot was flying north along the coastline at about 600 ft above the ground when he saw an object in the water about 100 m from the coast. The pilot turned the helicopter towards the object and descended to take a closer look.

As the pilot approached the object the helicopter’s tail rotor hit the water which caused the helicopter to rotate to the right before the pilot lost control. The pilot closed the throttle, and the helicopter settled into the water, before rolling over to the right. Unharmed, the pilot escaped via the passenger door and swam to shore before walking back to the fishing camp he left earlier.

Flat light can completely obscure features of the terrain, creating an inability to distinguish distances and closure rates.

The pilot reported that the wind was about 20 knots with a high smoke haze and flat light conditions. Flat light is an optical illusion also known as ‘sector or partial white out’ that causes pilots to lose their depth-of-field and contrast in vision. Flat light conditions are usually accompanied by overcast skies inhibiting good visual clues. These conditions can occur anywhere in the world, primarily in snow covered areas but can also occur in dust, sand, mud flats or over water. Flat light can completely obscure features of the terrain, creating an inability to distinguish distances and closure rates. It can give pilots the illusion of ascending or descending when actually flying level.

The dangers of flying helicopters over water have long been recognised. In July 1985 Robinson Helicopter Company issued 

about the hazards of flight over water, making special reference to the potential for pilots’ loss of depth perception over water. The safety notice recommended maintaining a height of 500 ft AGL and avoiding manoeuvres over water below 200 ft AGL.

Read the final report: Loss of control involving a Robinson R22, VH-HTD, Princess Charlotte Bay, Queensland, on 9 December 2012

An accident involving a Cessna 172N highlights the importance of lodging a Search and Rescue Time (SARTIME) Plan or flight note before flying.

The accident occurred on 7 November 2012, when the pilot of a Cessna 172N crashed his aircraft in a remote paddock near Brisbane while practising for a flight test. The pilot had not submitted a flight plan, nor had he left a flight note with a responsible person or lodged a Search and Rescue Time (SARTIME) with Airservices Australia. The pilot reported having little memory of the flight but said he had planned to fly to the southern training area to practise holding heading and altitude for his upcoming flight test.

Basic safety preparation before each flight could save your life and, at the very least, speed up your rescue.

Following the accident the pilot recalled regaining consciousness and crawling to the aircraft to broadcast a distress call on the aircraft radio. The aircraft was fitted with a personal locator beacon (PLB) but the pilot was unable to locate it after the accident to activate it.

An aircraft in the area reported hearing two faint mayday calls on the Brisbane Centre Frequency. These were not heard by the Brisbane Centre. The area controller requested the pilot of another aircraft in the area to track south from Kagaru to investigate. At about 1410, the crashed Cessna was spotted in a paddock. The pilot was the only person on board and had suffered severe injuries as a result of the accident. The ATSB assessed that the aircraft had been airborne for around 45 minutes, placing the accident about 3 hours before the aircraft was located.

The flight had not been authorised by an instructor prior to the flight. The flying school has now amended their procedures to ensure that no student pilot is provided with aircraft keys before the flight is authorised.

Read the final report: Collision with terrain involving Cessna 172N, VH-JGR, near Kagaru, Queensland, on 7 November 2012

The ATSB continues to emphasise the importance of maintaining effective communication at non-towered aerodromes, after an airspace-related incident involving a Beech 200 Kingair, and an Ag-Cat bi-plane at Swan Hill Aerodrome, Victoria.

The incident occurred on 21 November 2012, when the Kingair was approaching to land on runway 26 at Swan Hill. The pilot had broadcast the aircraft’s position and his intentions both when joining the circuit, and again when turning onto base leg. There was no response. When the Kingair was about 2.7 km from the runway 26 threshold, the pilot noticed a crop-spraying bi-plane, commencing a right descending turn ahead of him, approaching the same runway.

The pilot of the Kingair immediately made a radio broadcast but received no response. The pilot of the Kingair elected to continue the approach, and monitor the biplane carefully. Both aircraft landed safely. 

Communication at non-towered aerodromes is an ongoing safety concern...

The ATSB investigation found that the biplane was not fitted with a radio. The pilot normally maintained a listening watch on a hand-held radio device. However, to avoid damage from the weather and chemicals he removed the hand-held radio when the aircraft was not flying. On this occasion, the pilot had inadvertently left the radio at home. The bi-plane pilot reported conducting a thorough visual check of the runway 26 approach as he joined the circuit, but did not see the Kingair.

Communication at non-towered aerodromes is an ongoing safety concern for the Australian Transport Safety Bureau. ATSB research has found that of the 709 safety occurrences at non-towered aerodromes during 2003–08, 388 were attributed to a breakdown in communication. Safety around non-towered aerodromes has been highlighted in the ATSB’s Safety Watch initiative.

Read the final report: Airspace related event involving Kingair, VH-VAH and Ag-Cat, VH-IFE, Swan Hill Airport, Victoria, on 21 November 2012, which contains more details about the incident and links to useful educational material.

ATSB investigators have found that the fatal aircraft accident in New South Wales in 2012 was the result of a situation in which many pilots have found themselves: flying into weather conditions that cannot be dealt with. This is a frequent accident risk that the ATSB has been drawing to the attention of Australia’s general aviation community.

The accident occurred on 4 June 2012, as the pilot flew a Cessna 182Q from Walgett to Mudgee. The pilot, the only person on board, was flying under the Visual Flight Rules (VFR), a set of regulations that dictated he could fly only under favourable weather conditions. He had taken off in good weather conditions, and climbed to 5,500 ft. 

From 2006 to 2010, there were 72 such occurrences reported to us, and seven of those resulted in fatal accidents. Fourteen people were killed in these accidents.

During the flight, however, the cloud base lowered, and the pilot descended the aircraft to avoid flying in Instrument Meteorological Conditions (IMC). These are conditions where a pilot has limited visibility and will need to use aircraft instruments to fly safely. The aircraft descended until it was flying about 1,000 ft above flat terrain, either close to or in the cloud. While flying at that level the aircraft crashed into a rock face in mountainous terrain near Tooraweenah, NSW. The pilot died in the accident and the aircraft was destroyed. 

“The issue of pilots who fly into IMC while operating under VFR is an ongoing concern to the ATSB,” said Martin Dolan, Chief Commissioner of the ATSB. “From 2006 to 2010, there were 72 such occurrences reported to us, and seven of those resulted in fatal accidents. Fourteen people were killed in these accidents. Essentially, about one in ten VFR into IMC events results in a fatal outcome.”

The ATSB has been working to educate pilots about the dangers surrounding VFR into IMC. A booklet providing examples and advice on the subject forms part of the ATSB’s well-received Avoidable Accidents series. 

The ATSB’s Avoidable Accidents booklets, including Accidents involving Visual Flight Rules pilots in Instrument Meteorological Conditions, feature case studies on regularly occurring accidents that could have been prevented with good flight management and preparation. The booklets also provide helpful hints and strategies to help pilots stay safe when flying.

Read the final report: Visual Flight Rules in Instrument Meteorological Conditions and controlled flight into terrain involving Cessna 182Q, VH-CWQ, 15 km north of Tooraweenah, New South Wales, on 4 June 2012, which provides links to further resources.

A report released today by the ATSB identifies important opportunities to improve the safety of amateur-built aircraft in Australia.

Over the past three decades, amateur-built aircraft (aircraft built for personal use from an original design, established plans or kit, which are not entirely built and assembled in a factory) have become increasingly popular in Australia. This is the first detailed examination of their safety record. The ATSB’s research has identified key differences in the safety record of amateur-built aircraft when compared with similar factory-built aircraft and established an important baseline on which to improve safety in this growing sector of the aviation community. 

“Between 1988 and 2010, there was a significant difference in the accident rates of amateur-built aircraft and comparable factory-built certified aircraft flying similar operations,” said Dr Stuart Godley, manager of the ATSB’s safety research section. “In fact, the amateur-built accident rate was three times higher.” In addition, the fatal and serious injury accident rate was over five times higher in amateur-built aircraft, in particular due to relatively more serious injury accidents.

Builders of amateur-built aircraft should select, install and maintain aircraft engines carefully as engine issues are the most likely reason for an accident to occur.

“Overall, the pilots of amateur-built aircraft are significantly more experienced as pilots,” said Dr Godley. “They’ve been flying for a long time, they know aircraft, and they want the challenge and intellectual satisfaction of building a customised aircraft. Some of the aircraft are one-offs—unique designs—but the majority are either built from plans or a prefabricated kit that they’ll buy and put together themselves.”

However, pilots involved in accidents in amateur-built aircraft are significantly less experienced on the aircraft type that they were flying at the time of the accident. More than half of all amateur-built aircraft accidents occur prior to the pilot accumulating 35 hours on the aircraft type. This included owner-builders and recent purchasers of second-hand amateur-built aircraft. 

A significant finding is that over half of the accidents were precipitated by mechanical events, which were mainly complete or partial engine failures. Although common during the amateur-built phase one test period (first 25 to 40 hours), mechanical failures were also significantly more common after this test phase when compared with factory-built aircraft. 

A quarter of accidents were from loss of aircraft control, generally due to aircraft handling issues involving pilots with limited experience on the aircraft type. However, structural failures were not common precursors in amateur-built aircraft accidents.

“We are encouraging owners of amateur-built aircraft to ensure that they have adequate training in the same type of aircraft before operating the aircraft they have built, or purchased second-hand,” said Dr Godley. 

There are very few suitable aircraft available for type-training and instruction for amateur-built aircraft and the ATSB found that 20 per cent of pilots in these accidents had less than 10 hours experience on the aircraft type. Owners of amateur-built aircraft should ensure they have adequate training on type before operating new built or purchased aircraft.

Builders of amateur-built aircraft should select, install and maintain aircraft engines carefully as engine issues are the most likely reason for an accident to occur. Careful consideration to occupant protection at the time of building is also encouraged as serious injuries have been disproportionally more common.

Read the research report: Amateur-built aircraft Part 2: Analysis of accidents involving VH-registered non-factory-built aeroplanes 1988-2010

The Australian Transport Safety Bureau is drawing pilots’ attention to the effects of sun-glare when flying, after a Robinson R22 crashed into Lake Marradibbadibba in South Australia. 

The accident occurred at about 1520 on 31 October 2012. The pilot (the only person on board) had commenced mustering in the helicopter on Innamincka Station at about 0730 that morning. Due to flying low over the sandy and swampy terrain, the helicopter’s windscreen became dirty, leading to poor visibility. During one break, the pilot tried to clean the windscreen with water but this did not improve visibility. 

The accident demonstrates the effect
that sun-glare can have when relying
on visual cues.

The accident happened when the pilot conducted a low-level turn over the edge of the lake and experienced significant sun-glare from the water.  Even though he was wearing sunglasses, the pilot became disoriented due to the sunlight and dirty windscreen. A few seconds later, the helicopter crashed into the surface of the lake and sank rapidly into 2.5 to 3 m of water.

The pilot was not wearing a helmet that day because it was damaged. Nevertheless, he escaped the accident without injury and swam to shore. The helicopter was seriously damaged.  

The accident demonstrates the effect that sun-glare can have when relying on visual cues. In addition, although the pilot was uninjured as a result of this accident, previous ATSB investigations have shown the benefit of wearing a helmet. 

The US Federal Aviation Administration (FAA) has conducted research into sunlight and its association with aviation accidents. A link to that report, along with more details of the accident can be found in the investigation report AO-2012-146.