Three important lessons have emerged from the ATSB’s investigation into the capsize of the tug Adonis at Gladstone, Qld on 11 June 2011:

• Masters of tugs, regardless of size, need to be actively aware of the signs that a tug might be in danger of capsizing and what to do to lessen this danger. 
• In multiple tug operations, masters need to plan the passage and consider the speed of the passage and when it is time to release the towline. 
• It is also essential that masters communicate frequently throughout the passage bring any concerns about speed to the other master’s attention. 

On 11 June the harbour tug Adonis, which had four persons on board, was engaged in an operation with a second tug, Wolli, to move an Australian registered unmanned steel flattop dumb barge (Chrysus) in the port of Gladstone, Queensland. Adonis capsized during the operation. Three of the four persons on board escaped but the fourth drowned in the wheelhouse. 

The tug’s crew were not able to release the towline using the towing hook’s quick release arrangement before the tug capsized.

The ATSB found that while the masters of the two tugs were aware of the risk of capsize, neither of them realised that Adonis had entered a classic capsize scenario when it moved abaft of the barge’s port bow before the barge had begun to slow down. The barge’s speed was not reduced in time to allow Adonis’s master to regain control of the tug and manoeuvre it back into a safe position ahead of the barge. The tug’s crew were not able to release the towline using the towing hook’s quick release arrangement before the tug capsized. 

Investigations into the accident found that the retrospective fitting of a set of ‘H’ bitts to the tug aft of the towing hook had a detrimental effect on the tug’s manoeuvrability. The fitting of the ‘H’ bitts and a towing winch also resulted in Adonis being unstable when undertaking towing operations over the stern. This fact was never identified by the tug’s owners because the tug’s stability was not recalculated after the fitting of the additional equipment. 

Sea Swift, the owners of Adonis, have produced new procedures covering the quick release arrangements on its tugs and enhanced the training and familiarisation of its crews with these arrangements. The company has also reviewed all of its tugs’ towing and quick release arrangements and introduced regular testing of the equipment. They have also implemented a program to review all stability data for tugs purchased overseas. Sea Swift has also employed an experienced training manager to review and monitor the company’s health and safety practices. A review of Sea Swift’s training assessment for new masters has extended the period of training to include mentoring and supernumerary runs with other masters to develop a greater understanding of towing requirements.   

Read the final report: Capsize of the Australian registered tug Adonis, at Gladstone, Queensland, on 11 June 2011

Following a fatality at sea, the Australian Transport Safety Bureau is reminding mariners of the inherent dangers surrounding the routine task of rigging a pilot ladder.

• The seaman fell off the platform and hung from his harness while shouting for help.
• Rigging a pilot ladder while working over the side of a ship can be a hazardous task and it is imperative that all the precautions necessary to prevent a person falling overboard are taken.

On 17 November 2011, a seaman was rigging a combination pilot ladder for boarding a harbour pilot on the container ship MSC Siena near Rottnest Island off the port of Fremantle, Western Australia. (The harbour pilot has local knowledge and expertly pilots the ship safely into the port). The ship’s crew had done the task more than 30 times in the past two months. The procedure for this routine task involved the seaman, wearing a full body harness, securing the pilot ladder, which is made of rope and wood to the bottom platform of the accommodation ladder (a more rigid, staircase-type ladder with handrails and a horizontal lower platform).

The weather was rough and the boatswain was supervising the crew rigging the pilot ladder. He saw a large wave suddenly strike the underside of the accommodation ladder’s bottom platform on which the seaman was working. The seaman fell off the platform and hung from his harness while shouting for help and trying to hold on to the pilot ladder. His legs were submerged in the rough seas which were pounding his body against the ship’s side, the platform and the pilot ladder, and repeatedly breaking his hold on the ladder.

An immediate search initiated by Australian search and rescue agencies failed to find the seaman.

The boatswain and two other crew members on deck tried to pull the seaman up by heaving on the harness rope. However, he was caught under the accommodation ladder’s bottom platform. After about 4 minutes, the seaman slipped out of his harness. Submerged, and making no attempt to swim, he drifted past the ship and the crew lost sight of him.

An immediate search initiated by Australian search and rescue agencies failed to find the seaman. His boots and all the lifebuoys thrown overboard by the crew were located and recovered.

Occurrences where a person has fallen overboard are not unusual in the maritime industry. In many cases, the person is either not found or recovered alive. In 2010, a report published by the United Kingdom’s Marine Accident Investigation Branch documented a number of such occurrences. Inadequate risk assessments and/or deficiencies with ladders and associated equipment generally, were found to have contributed to those occurrences.

Since the accident, MSC Siena’s management company has taken a number of steps to improve safety during the rigging of pilot ladders. Amongst other initiatives, it has implemented a major revision to its work permit system for working over the side, which now specifically addresses the task of rigging a combination pilot ladder. On board training has been improved and a fleet wide safety campaign was carried out.

Read the final report: Man overboard fatality from the container ship MSC Siena, off Fremantle, Western Australia, on 17 November 2011, which provides a detailed description of the accident, and the measures aimed at improving the safety of mariners.

Air traffic control (ATC) local procedures need to be unambiguous and encompass all possible operational circumstances. That is the safety message arising from the loss of separation between a Cessna 402C and a Cessna C210 that occurred 6 km north of Cairns, Queensland on 23 November 2011. Effective radar navigation guidance is also important when positioning an aircraft for an approach. 

The C402 was conducting an instrument landing system (ILS) approach for runway 15 at Cairns airport and was 1.8 NM (3.3 km) from the airport when the pilot initiated a missed approach from a height of 1,000 feet in instrument meteorological conditions. At the time, the C210 was on the same ILS approach and was 6.4 NM (11.9 km) behind the C402. About 1 minute after the pilot turned left to establish the aircraft on the missed approach track, the distance between the two aircraft reduced below the required ATC separation standard.

Airservices has amended the local procedure to assist with the clarity and intent...

The ATSB identified that a local ATC procedure published, in part, to assist ATC in separation management during a missed approach event, was not clear and was subject to varying interpretations. This resulted in the spacing between the aircraft being closer than intended when the pilot of the C402 commenced the missed approach. The local procedure did not fully consider all operational aspects that could lead a pilot to initiate a missed approach in instrument meteorological conditions above the procedure-defined minimum cloud base height. 

In response to this occurrence, Airservices has amended the local procedure to assist with the clarity and intent and to enforce minimum flow (distance) spacing, and has updated controller missed approach procedures refresher training. The updated training will increase controller awareness of separation assurance issues relating to consecutive approaches and ensure that controllers give due consideration to the broad range of aircraft types using straight-in approaches. 

Read the final report: Loss of separation between VH-TFK and VH-PDP, 6 km north of Cairns, Queensland, on 23 November 2011

• Pilots should seek the advice of a Designated Aviation Medical Examiner (DAME) if they become aware of any condition that could affect their ability to safely carry out the privileges of their aviation licence.

On 3 September 2011 the pilot and one crewman in a Robinson R-44 helicopter departed an airstrip located near the Kumarina roadhouse, approximately 150 km south of Newman, Western Australia.

The crew were conducting low-level geophysical survey operations when the pilot was observed to have slumped forward in the seat. The crewman, who was seated behind the pilot, made unsuccessful attempts to rouse the pilot. The helicopter subsequently impacted terrain causing significant injuries to the crewman and the pilot. After the impact the pilot regained consciousness but died of his injuries before medical help arrived.

Pilots must provide accurate and complete information on their medical questionnaire and seek medical advice for any condition that could affect their ability to fly safely. 

The ATSB found that the pilot held a Class 1 Aviation Medical Certificate with no restrictions despite inconsistencies in recorded information in the pilot’s aviation medical questionnaires and one previous unconsciousness episode being recorded. If the correct information had been documented, further medical tests may have been required and the results used to better assess the pilot’s medical status.

During the investigation, CASA was advised of the reporting inconsistencies in the pilot’s aviation medical questionnaires. In response, CASA confirmed that the medical section of its website is being reviewed and guidance material on medical issue reporting requirements will be available on the website when the work is complete.

In addition to regular aviation medical assessments, pilots should seek the advice of a Designated Aviation Medical Examiner (DAME) if they become aware of any condition that could affect their ability to safely carry out the privileges of their aviation licence. It is also important for pilots to check the information documented in their aviation medical assessment for accuracy and completeness to allow for accurate assessment of their medical status and any risk to the safety of flight.

Read the final report: Pilot incapacitation while operating a Robinson R44, VH-HCA, 180 km south-south-west of Newman, Western Australia, on 3 September 2011

Report highlights the importance of good flight crew communication to ensure a shared understanding of an aircraft’s system status.

• The captain under training misunderstood the command from the training captain, which led to the early rotation.

On 6 February 2012 the flight crew of an Airbus A320-232, registered VH-JQX and operating as Jetstar Flight 745, commenced take-off from runway 16R at Sydney Airport, New South Wales. The flight crew consisted of a training captain and a captain under training. The captain under training was occupying the left seat and conducting the duties of captain.

During take-off, one of the thrust levers was inadvertently moved forward of the required detent, which resulted in a thrust setting reversion to manual mode. The training captain identified the issue and initially made the standard calls to the captain under training to indicate the issue with the thrust lever.

The captain under training was transitioning from another aircraft type to the A320 and the manual thrust mode on the A320 was consistent with his experience of a normal take-off on the previous aircraft type.

The training captain made a call to indicate that the take-off should continue with maximum thrust selected, and the captain under training began rotating the aircraft below the required rotation speed. At about that time the training captain increased the thrust levers to the maximum thrust setting. After noting the aircraft’s airspeed was below the required rotation speed, the captain under training discontinued the rotation until a suitable airspeed was achieved before commencing the climb.

The ATSB found that the captain under training misunderstood the command from the training captain, which led to the early rotation. The training captain recognised the thrust lever asymmetry situation, however, the captain under training did not, and this resulted in a miscommunication that was not resolved effectively between the crew.

In addition, the captain under training was transitioning from another aircraft type to the A320 and the manual thrust mode on the A320 was consistent with his experience of a normal take-off on the previous aircraft type. Following this incident, Jetstar have incorporated a module into their simulator training for all pilots, covering incorrect thrust settings at take-off. They have also released a communication to pilots on the responsibilities of the pilot in command in operational events.  

Read the final report: Inadvertent thrust lever asymmetry during the take-off roll involving an Airbus A320, VH-JQX, Sydney Airport, New South Wales, on 6 February 2012

The trailing bogie on the 47th wagon of a freight train derailed after traversing the Carlton Parade level crossing at Port Augusta, SA. The wagon travelled over a second level crossing and re-railed itself when it entered a third level crossing about 1,300 m later.

• Railway track operators must assess and manage track defects thoroughly to avoid derailments.

The derailment of the 47th wagon of a freight train at Port Augusta, South Australia highlights the importance of rail transport operators carrying out thorough assessments and management of track conditions. 

On 6 May 2011, the trailing bogie on the 47th wagon of freight train 4PM6 derailed after traversing the Carlton Parade level crossing at Port Augusta. The wagon travelled over a second level crossing and re-railed itself when it entered a third level crossing about 1,300 m later. 

The defects had not been adequately assessed and controlled in accordance with the ARTC Track and Civil Code of Practice.

The train continued towards Adelaide before it was stopped at Winninowie after the network controller had been alerted that the train was emitting sparks and that the half-boom barriers remained down with warning devices continuing to operate at the two level crossings. 

In investigation report RO-2011-008, the ATSB found that multiple geometric rail defects needing urgent attention had been detected by a track geometry car inspection three months before the derailment. As a result, there was a 30 km/h temporary speed restriction (TSR) in force at the time. The defects had not been adequately assessed and controlled in accordance with the Australian Rail Track Corporation (ARTC) Track and Civil Code of Practice and the 30 km/h TSR was probably inadequate to minimise the risk of derailment. The ATSB also found that the track geometry defect exceedance reports did not contain fields to record the date and time as confirmation that field inspections had been carried out in accordance with the Code of Practice. 

As a result of the accident, the ARTC has, through its Alliance Partner Transfield Services, undertaken additional training on the ARTC Track and Civil Code of Practice. This includes the necessary responses to situations where there are multiple localised geometric defects. The ARTC is also developing an improved reporting format for data from geometry car measurements.

Read the final report: Derailment of bogie on freight train 4PM6, at Port Augusta, South Australia, on 6 May 2011

Pilots and operators need to inspect and maintain fuel cap seals to prevent the ingress of water into fuel tanks.

• An inspection of the aircraft wreckage found evidence of water in the right tip tank and airframe fuel filter bowl.

On September 2012, a Piper PA-32 was being operated on a private scenic flight near Yea, Victoria. About 5 minutes after departing, at about 1,000 feet above ground level, the pilot changed the fuel selection from the left main tank to the right tip tank. About 3 minutes later, when at about 800 ft the engine failed. The pilot changed the fuel selector back to the left main tank and placed the fuel mixture and throttle control full forward, but the engine did not respond. As a result, the pilot elected to conduct a forced landing.

The deterioration of fuel cap seals can allow the ingress of water into fuel tanks.

The pilot moved the throttle to the idle position and prepared for landing. During the landing the pilot noted that the engine power had been restored. The aircraft subsequently impacted two fences and sustained substantial damage.

Subsequent inspections found water contamination in the fuel tanks. Prior to the flight, the aircraft had been sitting idle for several months, fully fuelled, in a hangar. The pilot reported that he had washed the aircraft several months earlier and speculated that water may have entered the tank through the fuel cap.

The deterioration of fuel cap seals can allow the ingress of water into fuel tanks. CASA Airworthiness Bulletin (AWB 28-008) Water contamination of fuel because of failure of fuel filler cap contains information on inspecting fuel filler and caps and conducting pre-flight inspections of fuel filler/caps and fuel samples.

Read the final report: Engine failure involving Piper PA-32, VH-FAJ, near Yea, Victoria, on 22 September 2012

Two aircraft proximity events on the same day have reinforced the point that it is critical for pilots to broadcast and actively listen to the CTAF and maintain a vigilant lookout at all times.

• Pilot should not hesitate to call and clarify another aircraft’s position and intentions.
• it is critical for pilots to broadcast and actively listen to the CTAF and maintain a vigilant lookout at all times.

Two aircraft proximity events at Ballarat Airport on the same day have reinforced the point that it is critical for pilots to broadcast and actively listen to the Common Traffic Advisory Frequency (CTAF) and maintain a vigilant lookout at all times to enhance traffic and situation awareness. This is particularly important in a high traffic density environment.

The two incidents on 4 August 2012 involved Cessna 172S aircraft on convergent headings arriving at the same time at the airport. Both incidents were sighted by observers on the ground. In both cases one of the two pilots involved had been unaware that the incident had occurred.

A pilot should not hesitate to call and clarify the other aircraft’s position and intentions if there is any uncertainty.

In the first instance the aircraft passed in close proximity with about .2 NM lateral separation and 300ft vertical separation. In the second case, the distance reduced to 0.1NM laterally and 100ft vertically.

The pilots reported making CTAF calls but some differences between the pilots’ and observers’ recollections of events that could not be reconciled. Any radio broadcasts made by the pilots could not be verified as transmissions at Ballarat are not recorded. Ballarat airport experienced a reasonable amount of airport activity on that day.

ATSB reminds pilots that in accordance with Civil Aviation Advisory Publication 166-1 ‘…radio broadcasts should be made as necessary to avoid the risk of a collision or an airprox event. A pilot should not hesitate to call and clarify the other aircraft’s position and intentions if there is any uncertainty.’

Read the final report: Two aircraft proximity events at Ballarat Airport, Victoria, on 4 August 2012

A hard landing of a Cessna P206B at Monduran in Queensland is a reminder for pilots to conduct a go-around as soon as landing conditions appear unfavourable.

• A go-around is a standard manoeuvre when a pilot is not completely satisfied that the requirements are in place for a safe landing.
• The sooner a condition that warrants a go-around is recognised, the safer the manoeuvre will be.

On 29 September 2012, the aircraft departed Gympie on a private flight to Monduran, carrying the pilot and four passengers. During the landing at Monduran, the pilot noted the windsock was indicating gusty wind conditions but still decided to land.

A go-around is a standard manoeuvre when a pilot is not completely satisfied that the requirements are in place for a safe landing.

During the landing, at about 10 feet above the runway, the Cessna was struck by a significant wind gust. The aircraft bounced and the pilot applied a small amount of power in an attempt to regain control. The aircraft was then struck by a second, more intense, wind gust before stalling and touching down hard on the nose landing gear. The pilot maintained control and the aircraft came to a stop.

Although no one was injured in the incident, the aircraft’s propeller, nose landing gear, and lower engine cowls were damaged.

The ATSB recommends pilots conduct a go-around as soon as landing conditions appear unfavourable. A go-around is a standard manoeuvre when a pilot is not completely satisfied that the requirements are in place for a safe landing.

The need for a go-around may occur at any stage during the approach and landing. However, the most critical go-around is one initiated very close to the ground. Consequently, the sooner a condition that warrants a go-around is recognised, the safer the manoeuvre will be.

Read the final report: Hard landing involving Cessna P206B, VH-EGG, Monduran, Queensland, on 29 September 2012

The inadvertent retraction of an Aero Commander’s landing gear on the runway shows the ease with which habitual piloting actions can result in an error.

• During a landing roll, pilot inadvertently retracted the landing gear of an Aero Commander 500S.
• Pilots should take the time to identify any control lever before they action it.

On 21 August 2012, at about 1430 Eastern Standard Time, an Aero Commander 500S registered VH-YJS (YJS) departed Charleville Airport, Queensland for Brisbane Airport via, Roma, Dalby and Toowoomba on a freight only charter flight under the IFR. The pilot was the only person on board.

This resulted in the main gear collapsing and the aircraft sliding for a short distance before coming to rest on the runway.

During the landing roll the landing gear was inadvertently retracted, and the lower fuselage contacted the runway. The pilot exited the aircraft without injury however the lower fuselage of the aircraft was damaged.

A manual safe pin was incorporated as a design feature to prevent inadvertent retraction of the landing gear. However, operation of the gear lever and safe pin together had become an automatic response by the pilot and the effectiveness of the safe pin as a countermeasure reduced. Pilots are reminded to positively identify any control lever before actioning.

The Aero Commander 500S departed Charleville Airport in Queensland bound for Brisbane airport via Toowoomba on a freight charter flight. About 300 m into the landing roll at Toowoomba airport, the pilot inadvertently retracted the landing gear while attempting to retract the aircraft’s wing flaps. This resulted in the main gear collapsing and the aircraft sliding for a short distance before coming to rest on the runway. The pilot, the only person on board, survived the accident without injury.

A manual ‘safe’ pin had been incorporated as a design feature to prevent inadvertent retraction of the landing gear. However, the pilot’s operation of the gear level and safe pin at the same time had become an automatic action, reducing the effectiveness of the safe pin as a countermeasure.

As a result of this accident, the operator has taken a number of safety actions, including modifying the landing gear control, and implementing random flight checks by check and training captains. In addition, the ATSB is encouraging pilots to take the time to identify any control lever positively before they action it.

Read the final report: Inadvertent landing gear retraction involving Aero Commander 500-S, VH-YJS, Toowoomba Airport, Queensland, on 21 August 2012, which contains useful information on skill-based errors and muscle memory.