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

The ATSB has released its investigation report into the 18 November 2009 ditching of an Israel Aircraft Industries Westwind 1124A that occurred off Norfolk Island. The report found that the need to ditch the aircraft arose from incomplete pre-flight and en route planning and the failure to assess that a safe landing could not be assured before it was too late to divert. The investigation also confirmed the benefit of clear in-flight weather decision making guidance and its timely application by pilots in command.

The flight was an aeromedical retrieval from Apia, Samoa bound for Melbourne via Norfolk Island. It was carrying a pilot in command (PIC), copilot, a doctor, a nurse, a patient and one passenger. The pilot submitted a flight plan to leave Apia bound for Norfolk Island, a journey of four and a half hours.

The PIC received the latest aerodrome forecast (TAF) for Norfolk Island from the briefing officer while submitting the flight plan. The forecast was valid beyond the period of the flight and indicated that the weather conditions would be suitable for landing. Based on that forecast, there was no requirement to plan or to carry fuel for the possibility of a diversion to an alternate airport.

Various weather reports and forecasts, both routine and special, were available en route through air traffic control. Special weather reports (or SPECIs) are issued when there is significant deterioration or improvement in airport weather conditions. The flight crew did not realise the significance of the changed conditions reported in a SPECI for Norfolk Island until after they had committed to landing on Norfolk Island. By this time they had insufficient fuel reserves to divert to another destination.

The crew attempted a night approach and landing on Norfolk Island, but the weather conditions prevented them from seeing the runway or its visual aids, and therefore, from landing. After four failed attempts, the PIC elected to ditch the aircraft in the sea 3km south-west of Headstone Point on Norfolk Island, before its fuel was exhausted. The aircraft broke in two after ditching. All the occupants escaped from the aircraft and were rescued by boat, although two sustained serious injuries. 

The report found that the operator's procedures and flight planning guidance managed risks consistent with regulatory provisions but did not minimise the risks associated with aero-medical operations to remote islands. Clearer guidance on the in-flight management of previously unforecast, but deteriorating destination weather might have assisted the crew to consider and plan their diversion options earlier.

As a result of this accident, the operator changed its guidance for the management of previously unforecast deteriorating destination weather. Satellite communication has been provided to crews to allow more reliable remote communications and its flight crew oversight systems and procedures have been enhanced. CASA is also developing a number of Civil Aviation Safety Regulations covering fuel planning and in-flight management, the selection of alternate destinations and extended diversion time operations.

Read the final report: Fuel planning event, weather-related event and ditching involving Israel Aircraft Industries Westwind 1124A, VH‑NGA, 6.4 km west-south-west of Norfolk Island Airport, on 18 November 2009

The ATSB's investigation into the loss of the main rotor drive on a Robinson R44 Raven II (AO-2011-088) helicopter found that it was associated with corrosion and subsequent fatigue failure of the main rotor gearbox gear carrier as a result of water present in the main rotor gearbox.

The helicopter, registered VH-ZWC, had departed Darwin Airport bound for Bamurru Plains in the Northern Territory on 28 July 2011. About 30 minutes into the flight the aircraft lost its main rotor drive and the pilot conducted an autorotative descent and landing. There were no reported injuries.

The helicopter manufacturer advised that there had been a similar instance of corrosion-related gearbox failure in an R44 helicopter. In each case the aircraft had been operated in similar climatic conditions in Australia's tropical north and had been stored outside, not in hangars.

The helicopter manufacturer has now modified the design of the gear carrier to incorporate a metallic cadmium surface plating to improve the corrosion resistance of the assembly.

In May 2012 the Civil Aviation Safety Authority (CASA) released Airworthiness Bulletin 63-008, to raise awareness of the hazards associated with R44 gearbox internal corrosion due to water ingress.

The CASA bulletin made several recommendations to reduce the risks to those carrying the original assemblies, including:

• that operators and maintainers requesting their maintenance facility conduct a MRGB oil inspection for any contaminants such as water, rust or paint
• where appropriate store the rotorcraft under cover, or cover the main rotor mast and head assembly during inclement weather conditions
• during lengthy periods of storage or inactivity in tropical conditions take additional preservation action (seek advice from Robinson Helicopter Company)
• in the event of a MRGB warning chip light indication, land the helicopter immediately and have the issue investigated by a LAME in accordance with the manufacturer's instructions
• report all water, rust and paint contamination of the MRGB oil system and any corrosion to CASA.

Read the final report: Loss of main rotor drive Robinson Helicopter R44, VH-ZWC, 83 km east of Darwin Airport, Northern Territory, on 28 July 2011

Read CASA's Airworthiness Bulletin 63-008 (Opens in a new tab/window)