The ATSB investigation into an aircraft’s collision with terrain in Queensland has highlighted the vital importance of avoiding fuel contamination, and the value of using all safety equipment, including shoulder harnesses, in case an accident does occur.

On 19 June 2012, the Cessna 182P departed Mayvale Station, about 53 km from Cunnamulla, Queensland to conduct an aerial inspection of the property. The pilot, who was the only person on board, would later recall that, shortly after becoming airborne, at about 80 to 100 ft, the aircraft lost airspeed. Then, while conducting a forced landing, the aircraft clipped a tree. The next thing he could recall was being on the ground, out of the aircraft and unable to stand. The aircraft had collided with the ground and come to rest inverted. 

Although the aircraft was fitted with a single shoulder strap harness, the pilot had only fastened the seat belt. In order to afford the best possible protection against injury in the event of an accident, aircraft occupants should fasten both the seat belt and shoulder harness, where provided, particularly for take-off and landing.

A search was mobilised when the pilot failed to return and could not be reached by radio. Three hours after the accident, the seriously injured pilot was found. Although the aircraft was fitted with an Emergency Locator Transmitter (ELT), it had not activated, and a personal ELT carried by the pilot in the aircraft was inaccessible. 

The day before the accident flight, the pilot refuelled the aircraft from drum stock kept as an emergency fuel supply. The pilot did not test the drum fuel for water or contamination. Following the accident, a considerable amount of water was found in a number of fuel samples taken from the aircraft, and in a sample taken from the drum. 

Checking fuel for water and other contaminants is something pilots can never be too careful about. The following publications provide further information relating to refuelling and fuel checks: 

• ATSB Avoidable Accidents No. 3 – Managing partial power loss after take-off in single-engine aircraft 
• Civil Aviation Order 20.9 titled Air service operations – precautions in refuelling, engine and ground radar operations(Opens in a new tab/window)
• Safety on the ground, provides advice on refuelling from a drum, and on the correct way to store a fuel drum 
• The Cessna Pilot Safety and Warning Supplements (1998) 

Pilots are encouraged to leave a flight note with a responsible person, and carry their personal ELT on them, so that it is readily available when most needed.

Read the final report: Collision with terrain - Cessna Aircraft Company 182P, VH-WTS, 53 km east-north-east of Cunnamulla, Queensland, on 19 June 2012

You can find this and other investigations in the ATSB’s Aviation Short Investigation Bulletin. The bulletin highlights valuable safety lessons for pilots, operators and safety managers.

A new aviation bulletin featuring ten investigation reports has just been released by the ATSB. The Aviation Short Investigation Bulletin issue 12 covers short, desk-based investigations that took place between April and July this year.  The bulletin covers incidents and accidents involving jet, turboprop and piston aircraft, and helicopters. None of the accidents were fatal; however, one pilot sustained serious injuries and some of the aircraft were seriously damaged or destroyed.

Short investigations cover incidents and accidents where the associated factors are usually well-understood and do not require more detailed investigations. Nonetheless, each investigation has the potential to produce important Safety Messages for pilots, operators and others in the aviation industry. The investigations also help the ATSB identify statistics and trends in air safety.

The incidents covered in the report include:

• Fumes event – Boeing 7373, VH-VBL (AO-2012-060)
• Take-offs without runway lighting (AO-2012-069)
• Partial power loss – Gippsland Aeronautics GA8, VH-WOV (AO-2012-062)
• Airspace related event – Amateur Built Van’s RV-8, VH-YGY (AO-2012-067)
• Fuel contamination – Cessna 182P, VH-WTS (AO-2012-083)
• Total power loss – Gippsland Aeronautics GA-8 Airvan, VH-FCK (AO-2012-092)
• Collision with terrain – Guimbal Cabri G2, VH-ZZT (AO-2012-055)
• Collision with terrain – Robinson R44 Raven 1, VH-HOU (AO-2012-078)
• Wirestrike – Robinson R44, VH-HIE (AO-2012-079)
• Collision with terrain – Schweizer 269C-1, VH-LTO (AO-2012-082)

Read the ATSB's Aviation Short Investigation Bulletin - Issue 12 

The investigation into the collision with water off Horn Island, Queensland (AO-2011-033) highlights the importance of pilots having enough sleep before a flight and for operators to manage potential fatigue risks.

On 24 February 2011 the pilot of an Aero Commander 500S commenced a freight charter flight from Cairns to Horn Island at 0445 Eastern Standard Time under the instrument flight rules. The aircraft arrived at Horn Island at about 0720 and the pilot advised air traffic control that he intended holding east of the island due to low cloud and rain. At 0750 he advised that he was north of Horn Island and intending to commence a visual approach. When the aircraft did not arrive a search was commenced but the aircraft was not found. It was eventually located on about 10 October 2011 on the seabed about 26 km north‑north‑west of the island.

The ATSB investigation found that the aircraft had not broken up in flight and that it had impacted the water at relatively low speed and a near wings-level attitude, consistent with it being under control at impact. There is insufficient evidence to determine why the aircraft impacted the water, however, several aspects of the flight increased risk. The pilot had only 4 hours sleep the night before the flight and the operator did not have any procedures or guidance in place to minimise the fatigue risks of early starts. In addition, the pilot, who was also the operator’s chief pilot had either not met the recency requirements or did not have an endorsement to conduct the types of instrument approaches available at Horn Island and other locations.

The operator ceased operations following the accident and therefore did not have the opportunity to improve its processes. CASA has issued a notice of proposed rule-making relating to flight crew fatigue management. In the case of single pilot public transport operations, this included a proposal to limit the duration of a flight duty period and the number of late night flight duty periods in certain circumstances.

Read the final report: Collision with water - Aero Commander 500S, VH-WZU, 26 km north-north-west of Horn Island, Queensland, on 24 February 2011

Severe turbulence and wind gusts are just some of the hazards prevalent in and around thunderstorms. The breakup in the air of a Cessna 210 on 7 December 2011 en route from Roma to Dysart in Queensland is a reminder to all pilots that to minimise the risk of structural damage or loss of control, thunderstorms should be avoided.

The pilot was conducting a private flight under visual flight rules when the outer sections of the wings and part of the tail separated. The ATSB investigation found that the aircraft had been structurally sound before the separation and no aircraft system defects were identified. The investigation showed that thunderstorms had been recorded in the area and cruise power setting had been maintained until an onboard engine monitoring system ceased recording.

Although the precise circumstances leading to the accident were not known, a combination of aircraft airspeed with the effects of turbulence and/or control inputs generated stresses that exceeded the design limits of the aircraft structure.

Airspeed is a critical factor in the stress sustained by an aircraft. Pilots need to be aware of the manoeuvring speed (VA) for the aircraft weight, and to control the airspeed so as not to exceed that value when full control deflection is required, or severe turbulence or wind gust are encountered

Read the final report: In-flight breakup - Cessna C210, VH-WBZ, 100 km north-north-west of Roma, Queensland, on 7 December 2011

The ATSB’s investigation MO-2011-001 into a thermal heater explosion on board the products tanker Qian Chi emphasises that ships’ crews need to remain vigilant to safety even when conducting repeated or seemingly simple tasks and need to consult equipment documentation and pay increased attention when tackling unfamiliar tasks. Crews also need to understand the importance of providing immediate and appropriate first aid to injured persons, especially burn victims.

On 16 January 2011, while Qian Chi was at anchor in Moreton Bay, Queensland, the ship’s number two oil-fired thermal oil heater exploded. The explosion seriously injured three crew members and severely damaged the thermal oil heater and surrounding equipment.

The ATSB investigation found that during maintenance the oil heater burner nozzle had been assembled incorrectly. This was because the crew lacked experience with the equipment and the manufacturer’s instructions were not clear and detailed. The nozzle leaked fuel into the furnace through the pre-ignition start sequence, the fuel was ignited when the burner igniter operated and the furnace exploded.

The ATSB also found that the crew were not aware of the importance of providing immediate and accepted first aid treatment for burn injuries. Deficiencies in the Brisbane port vessel traffic service procedures led to delays in providing emergency assistance.

As a result of the incident, the ships operators have renewed the burner equipment and altered the control system to better suit the fuel being used and the load demands on the heaters. The heater’s supplier is updating the documentation supplied with the machinery. Maritime Safety Queensland has undertaken a review of its procedures and practices to take into account the risks associated with ships within port limits but not at a berth and the emergency response required in such situations.

Read the final report: Thermal oil heater explosion on board the products tanker Qian Chi, at Brisbane, Queensland, on 16 January 2011

The accident involving a De Havilland Tiger Moth at Maryborough Airport on 27 January 2012 illustrates several of the points made in the ATSB’s Avoidable Accidents report Managing partial power loss after take-off in single engine aircraft (AR-2010-055).

In this instance, immediately after lift-off, the aircraft was observed to have a partial, intermittent power loss. The pilot continued the flight with the aircraft maintaining altitude or climbing slightly. At the upwind end of the runway, the aircraft made a climbing left turn before stalling and descending. The aircraft impacted the ground and the occupants died. The ATSB investigation found that the power loss was probably caused by a partial blockage of the aircraft’s fuel cock.

Pilots are reminded that continued power in such circumstances is unpredictable and the risk can be reduced by conducting a controlled landing at the earliest opportunity.

Read the final report: Collision with terrain - De Havilland DH-82A, VH-GVA, Maryborough Airport, Victoria, on 27 January 2012

• Avoidable Accidents No.3 - Managing partial power loss after take-off in single-engine aircraft

The ATSB’s investigation into a safeworking breach by Track Machine BC7 at Bogan Gate, NSW, highlights potential for confusion around terminology used in track occupancy authority (TOA) notices and the need for track personnel and operators to ensure they know the limits of their authority, before moving rail vehicles.

On 10 August 2011, John Holland Group (JHG) contracted a traffic officer to pilot track machine BC7 (a 176t shoulder ballast cleaner) from Denman Siding to Broken Hill. On 15 August 2011 the ARTC network control officer (NCO) issued a track occupancy authority (TOA) for the section of track between signal GJ149 at Parkes and the ‘down’ yard limit board at Bogan Gate until 1200. (The terminology ‘down’ is used within rail systems throughout Australia to describe the direction of travel by a rail vehicle. This direction is not determined by one specific point in Australia and changes from state to state, usually in reference to the direction the vehicle is travelling from the state’s capital city. In this instance the ‘down’ direction at Bogan Gate describes the movement of all track vehicles travelling west towards Broken Hill.)

On the same day track machine BC7 was en route from Narromine towards Broken Hill with an operator and the traffic officer on board. The traffic officer contacted the protection officer and was authorised to transfer the machine to the down yard limit at Bogan Gate. In fact, the crew took the machine to the platform at Bogan gate, which was beyond the limit of their authority.  

In its own investigation, JHG found that the incident may have been caused by limitations in the traffic officer’s local knowledge or misunderstanding of the terminology ‘up’ and ‘down’. JHG has taken action to verify their traffic officers’ competencies, method of safeworking and route knowledge and to review worksite protection and rolling stock transfer through multiple safeworking territories.

Read the final report: Safeworking breach – track machine BC7, Bogan Gate, New South Wales, on 15 August 2011 | ATSB

On 13 September 2012, the Australian Parliament passed the Transport Safety Investigation Amendment Bill 2012. The bill supports the establishment of the Australian Transport Safety Bureau (ATSB) as Australia's first national rail safety investigator.

From January next year, the ATSB will have the responsibility of investigating safety events on all passenger and freight rail networks across Australia; this is a key part of new national arrangements making rail travel safer for all Australians. At present, the ATSB is limited to investigations on interstate rail lines.

From next year, the ATSB will conduct more safety investigations across a greater range of safety matters and share the safety lessons that will save lives and prevent injuries.

Martin Dolan, the Chief Commissioner of the ATSB said;

"The ATSB is looking forward to taking on a bigger job in improving Australian rail safety through investigating accidents and incidents on all Australian rail networks. It is fundamentally important to rail safety that we learn what caused things to go wrong and prevent it from happening again."

"We have built up significant experience over the last ten years of conducting interstate rail investigations and we are ready to expand our jurisdiction as a part of the national rail safety reforms.  While we will be independent from the new national rail safety regulator and industry, we will be working with them to identify risks to safety that might be addressed to prevent future accidents", said Mr Dolan.

Consistent with the ATSB's current role and international best practice, the ATSB will be focussed on finding the factors that contribute to accidents and incidents so that lessons can be learned and shared in order to improve the safety of the rail systems across Australia.

"Our interest is in improving safety, not in allocating blame", Mr Dolan said. "We will have succeeded if we can prevent future accidents through thorough investigation and publicising and sharing the results."

Over the last 12 months the ATSB has recruited new rail investigators in readiness for the expanded role and negotiated financial and resource sharing arrangements with the states. 

"We will be making assessments of occurrences reported to us to determine which ones would benefit from an ATSB investigation in order to assist with improving future safety. Certainly where there are deaths or serious injuries, we will be there", said Chief Commissioner Martin Dolan.

• More information on the National Safety Investigation Reforms

The ATSB's report into the collision between the Australian fishing vessel Apollo S and the Liberian registered bulk carrier Grand Rodosi contains important messages for pilots and ships' crews.

The collision occurred at Port Lincoln, SA, on 8 October 2010 while Grand Rodosi was berthing. As a result of the collision, Apollo S was crushed against a wharf and sank. Grand Rodosi sustained small holes in its bow shell plating.

The investigation found that despite the pilot ordering astern movements, the ship's main engine did not respond. The chief engineer, who was operating the main engine start/fuel lever in the engine room control room, did not allow sufficient time for starting air to stop the ahead running engine. Consequently, when fuel was introduced into the engine, it continued to run ahead, despite the astern telegraph orders.

The investigation also found that the chief engineer's mistake was not noticed on the ship's bridge or in the engine control room until after the collision; that the master/pilot information exchange was less than optimal; and that bridge resource management could have been better during the passage to the berth.

Following the incident, Newlead Bulkers, the ship's managers, amended their on-board procedures to ensure crew monitor the direction of main engine turning after each engine order. They have also increased awareness through their fleet about this type of incident occurring.  

Flinders Ports, the provider of pilotage services in Port Lincoln, has revised their risk assessment for the manoeuvre undertaken during Grand Rodosi's berthing to include new preventative, as well as restorative, measures to be followed. Flinders Ports has also revised their pilotage passage plan to include indicative courses to be followed and speed zones. It is of paramount importance that pilots and crews remain aware of main engine movements and check engine tachometers following every movement to ensure that the engine is operating in the desired direction. This is particularly important when main engines are being operated in manual control.

In addition, pilots and the bridge teams should ensure that all necessary information is exchanged at the beginning of a pilotage, including courses to be followed and speeds at critical positions during the passage, so that all involved in the pilotage have a shared mental model and a good understanding of the pilotage before it begins.

Read the final report: Collision between the Liberian registered bulk carrier Grand Rodosi and the Australian registered fishing vessel Apollo S, in Port Lincoln, South Australia, on 8 October 2010

Today the ATSB released its report into the derailment of freight train 7AD1 at the Edith River rail bridge near Katherine in the Northern Territory on 27 December 2011. The derailment caused significant damage to the bridge and the rolling stock. A number of wagons derailed into the Edith River. The driver was uninjured but the co-driver suffered back injuries.

The ATSB found that the derailment was caused by the wash-away of the south eastern embankment, associated sub-grade and ballast on the approach side of the rail bridge. The extent of the wash-away meant that the track could not support the weight of the train and it collapsed. The wash-away resulted from a severe flood event caused by torrential rain in the aftermath of cyclone 'Grant'.

The train owner, Genesee & Wyoming Australia Pty Ltd (GWA) has undertaken a range of actions to enhance its policies, procedures and employee training for managing risks associated with severe weather events. GWA will also enhance its systems for alerting staff to severe weather events including flood risks.

The safety message from this event is that it is essential for rail network operators to have robust systems in place to monitor and mitigate the risk of severe weather events and ensure that the safety of railway operations is not compromised. 

Read the final report: Derailment of freight train 7AD1, at Edith River, near Katherine, Northern Territory, on 27 December 2011