Effective management of all aspects of track condition on tight curves will reduce derailment risk.
The ATSB’s investigation into the derailment of a Metro Trains Melbourne (MTM) passenger train near Rushall Station in Melbourne on 6 February 2016 has been released. The investigation was conducted by the Victorian Office of the Chief Investigator, Transport Safety, on behalf of the ATSB under the Transport Safety Investigation Act 2003.
At about 1650, the passenger train was negotiating the most severe mainline curve on the metro network when the lead bogie of the second car derailed.
The ATSB found that the leading right-hand wheel of the second car climbed the outside rail of the small-radius curve. The main factors contributing to the derailment were the geometry of a rail joint and the high coefficient of friction between wheel and rail. The train was being operated within the speed limit for this curve and the manner of its operation did not contribute to the derailment.
For small-radius curves, the effective management of track condition is critical to reduce the risk of flange-climb derailment.
The derailment at this point on the curve was triggered by a lateral angular discontinuity at a mechanical rail joint, resulting in a localised increase in the wheel-to-rail lateral force. The network’s track geometry standard did not preclude the presence of such a discontinuity.
It was also found that the train’s wheel flanges and the rail’s gauge-face had low levels of lubrication. The performance of rail lubricators on the metropolitan network had diminished prior to the derailment, leading to a deficiency in lubrication on the network.
While not mandated by MTM, a check rail on this small-radius curve (installed adjacent to the inner rail) would have provided an additional defence against flange climb and derailment.
A number of other safety factors were identified that were not directly causal to this incident. They included a high tolerance on allowable track geometry deviations at low-speed mainline locations, a failure to address a wide-gauge defect on this curve, and the ineffective locating of some rail lubricators within the network.
To reduce the risk of future derailments on similar curves, MTM has undertaken a range of actions including significant changes to the management of track condition and faults and the installation of new electronic lubricators.
A video message from ATSB Chief Commissioner Greg Hood...
A video message from ATSB Chief Commissioner Greg Hood who will again be sleeping without shelter on one of the longest nights of the year with leaders in business, community and government to help change the lives of Australians experiencing homelessness for this year's Vinnies CEO Sleepout.
The ATSB has completed the investigation into an operational non-compliance incident involving a GIE Avions De Transport Regional ATR72 at Cairns Airport.
On 4 September 2017, PNG Air charter flight CG950 was cleared for departure from runway 33 with via the CAIRNS TWO standard instrument departure (SID). This SID included an assigned heading component. The captain had not previously used a SID with an assigned heading component for a departure and selected the lateral navigation mode of the flight management system (FMS) for their initial departure.
The aircraft was cleared for take-off with an assigned heading of 335°M. The captain selected the heading bug to 335. The take-off was conducted as normal and as the aircraft climbed through 500 ft, the FMS, in lateral navigation mode, directed a right turn past the assigned heading. As the aircraft turned to 335°M, the FMS continued to command a right turn. The captain followed the FMS and reached a heading of 013°M.
To use an FMS effectively, flight crews need to have a thorough understanding of the system and the effect of each input and selection.
Upon identifying the deviation, the flight crew and air traffic control took immediate action to return the aircraft to its assigned flight path. The flight continued without further incident.
ATSB Executive Director of Transport Safety, Mr Nat Nagy, said the incident was a reminder to flight crews to ensure they use their FMS effectively and to cross-check their flight instrumentation.
“To use an FMS effectively, flight crews need to have a thorough understanding of the system and the effect of each input and selection,” Mr Nagy said.
“Flight crews also need to continuously cross-check their flight instruments and remain aware of the overall flight situation.
“You can never assume that an FMS route or course will be free from error. Always remember to cross-check the instrument displays to ensure that all indications agree.”
A fatal helicopter accident has led to the ATSB issuing a safety advisory notice.
Examination of the helicopter operator’s records revealed the deceased pilot, who was recently employed by the operator, had not undertaken HUET for nine years. The helicopter operator normally required company pilots to complete a HUET course every three years.
HUET involves a replica of a helicopter cabin and fuselage being lowered into a swimming pool and rolled inverted to simulate a crash situation. During the training students practice bracing for impact, identifying primary and secondary exit points, escaping the helicopter and surfacing techniques. ATSB Executive Director, Transport Safety, Mr Nat Nagy said that frequent under water escape training is an important factor in increasing the survivability of an in-water accident.
All helicopter operators involved with overwater operations are encouraged to ensure their aircrews are regularly trained in helicopter underwater escape techniques.
“In light of our initial investigation, the ATSB has contacted all helicopter operators that are involved in overwater operations to deliver a safety advisory notice,” Mr Nagy said. “The ATSB strongly recommends that aircrew and regular passengers on these sorts of operations receive training in under water escape to increase survivability in the event of a ditching such as this one.”
It is our melancholy duty to advise that Dr Rob Lee AO, passed away peacefully on Friday morning 27 April 2018.
It is our melancholy duty to advise that Dr Rob Lee AO, a great leader and aviation safety visionary passed away peacefully on Friday morning 27 April 2018.
In 1970, Dr Lee graduated from the Australian National University with First Class Honours in Psychology, winning the Australian Psychological Society Prize. In 1974, he completed his PhD in Psychology at the University of St Andrews, Scotland. His research was concerned with human performance in complex systems, with particular reference to aircraft.
In 1976, Dr Lee was appointed Senior Psychologist, Operational Command, Royal Australian Air Force (RAAF). He became the first RAAF psychologist to serve as a human factors specialist on RAAF aircraft accident investigation teams.
In 1983, Dr Lee joined the Bureau of Air Safety Investigation (BASI) as the Bureau’s first human factors specialist. He established and developed the Bureau’s capability in human factors, systems safety and research. Dr Lee became Director of BASI in 1989.
During his directorship, he transformed the Bureau from a purely reactive investigative agency to an innovative multi-skilled organisation that concentrated equally on proactive accident prevention and safety enhancement. As Director of BASI, he negotiated the memoranda of understanding to increase practical cooperation in air safety investigation in the Asia Pacific region with Indonesia, Singapore and Taiwan.
In 1999, Dr Lee was appointed Director of Human Factors, Systems Safety and Communications of the new multi-modal Australian Transport Safety Bureau (ATSB).
In 2000, he expanded his influence internationally in human factors and systems safety in aviation and in other high technology industries. He was a human factors analyst on the investigations into the Gulf Air A320 accident at Bahrain in August 2000, the Singapore Airlines B747 accident at Taipei in October 2000, and the mid-air collision between a B757 and a TU154M over Ueberlingen, Germany, in 2002.
He was a member of the Expert Panel on Safety Management Systems appointed by the Special Commission of Inquiry into the Waterfall, NSW, rail accident in January 2003.
He was a member of the Advisory Board of the NSW Independent Transport Safety and Reliability Regulator, and has been a member of the Nuclear Safety Committee of the Australian Radiation Protection and Nuclear Safety Agency for fifteen years.
Dr Lee was a Group Captain in the RAAF Specialist Reserve, in the capacity of a consultant, and regular training course lecturer, on aviation psychology, human factors, systems safety and air safety investigation within the Australian Defence Force. He was an adviser to the Board of Inquiry into the Royal Australian Navy Sea King accident that occurred in Indonesia in April 2005, and was an expert witness on the Board of Inquiry into the fatal Army Black Hawk accident that occurred on HMAS Kanimbla, off Fiji, in November 2006.
He was a member of the International Society of Air Safety Investigators, the European Association for Aviation Psychology (EAAP), and the Australasian Society of Aerospace Medicine. He was also Vice-President of the Australian Aviation Psychology Association. He lectured at the Singapore Aviation Academy on integrated safety management systems, and on human factors, systems safety and risk management.
Dr Lee was co-author with Professor James Reason, Captain Dan Maurino of ICAO and Captain Neil Johnston of Aer Lingus of the book ‘Beyond Aviation Human Factors’, published in 1995. He was an associate editor of the international journal ‘Human Factors and Aerospace Safety’, published by Ashgate, UK.
In 2000, Dr Lee was awarded the Aviation Human Factors Achievement Award by the Australian Aviation Psychology Association.
Dr Lee was a Fellow of the Royal Aeronautical Society, and a Fellow of the Chartered Institute of Logistics and Transport. In 1989 he won the Henry Wigram Award of the New Zealand Division of the Royal Aeronautical Society.
In 2003, Dr Lee was awarded an International Prize by the Captain A. G. Vette Flight Safety Research Trust of New Zealand. The award read: “Your work in the RAAF and as Director with the Australian Bureau of Air Safety Investigation has set an excellent example”.
In 2010, Dr Lee was awarded the Australian Bi-Centennial Award by the Guild of Air Pilots and Air Navigators (GAPAN), “in recognition of an outstanding individual contribution to Australian Aviation”.
From April 2011 to March 2012 he served as Technical and Air Safety Director of the GAPAN.
In the 2012 Queen’s Birthday Honours, Dr Lee was made an Officer in the General Division of the Order of Australia (AO): “For distinguished service to the aviation industry, to the development of air safety and accident investigation standards, and to national and international professional associations”.
In September 2014, he was awarded the 2014 Award of the European Association for Aviation Psychology for “outstanding achievements in Aviation Psychology”.
In December 2017, the ATSB’s primary conference room was named the Rob Lee Room in recognition of his outstanding contribution to improving transport safety in Australia.
Whilst he will long be remembered for such a significant contribution to aviation safety, he will also be remembered for his warmth, his love for his partner Sue and his family, his infectious smile, his international diplomacy, and for his musicianship, as lead guitarist in the Canberra band “Mid-Life Crisis”.
Investigation shows rail safety relies on effective systems design
On 11 August 2016, track maintenance was planned in the vicinity of Ballarat Railway Station. To protect the work group, three sets of points within the work area were Blocked to prevent them being operated from the train control system (TCS).
Later that day, the points unexpectedly moved when the TCS was used to establish a route for a train to approach the area.
The investigation, carried out by the Victorian Office of the Chief Investigator, Transport Safety, on behalf of the ATSB under the Transport Safety Investigation Act 2003, found the design and coding of the TCS did not allow point Blocking-functionality for points that lay outside the selected route, but within its overlap area.
Victorian Chief Investigator, Transport Safety, Chris McKeown, said although maintenance crews are now required to isolate points equipment prior to carrying out maintenance, it is also important that TCS equipment correctly blocks field equipment according to the Train Controller’s settings.
“It’s important that those involved in the design and installation of these systems ensure that they adequately cover the functionality and performance requirements for all potential operational circumstances at any particular location.”
As a result of the incident, the TCS designers have improved their design procedures, and check and testing processes to ensure that Blocking is provided for overlap points. They have also tested and modified, where necessary, other similar TCS systems.
ATSB Chief Commissioner has been recognised for his contribution to Australian aviation.
The A18 A/AA AIRSPACE Chairman's Award recognises leadership excellence and outstanding accomplishments, coupled with remarkable dedication and commitment to the industry.
Mr Hood said he was deeply humbled by the award, which was presented at the A18 AIRSPACE Awards Gala Dinner on Wednesday 18 April 2018.
“It has been a real privilege to be able to dedicate the majority of my working life to the continual improvement of the aviation industry. To receive this award is a great honour and I am very grateful to Aviation/Aerospace Australia.”
Mr Hood has more than 35 years of experience across a wide range of operational, training and management roles within the civil aviation industry.
It has been a real privilege to be able to dedicate the majority of my working life to the continual improvement of the aviation industry.
In his time as ATSB Chief Commissioner, Mr Hood has overseen a number of significant transport safety investigations and report releases across the three modes of aviation, rail and maritime.
Mr Hood began his career as an air traffic controller in the Royal Australian Air Force in 1980, serving at locations throughout Australia and in the Middle East. In 1990, he moved to the Civil Aviation Authority, a predecessor to what is now Airservices Australia to further his career as a civilian air traffic controller.
In 2002, Mr Hood was appointed to lead the management team in Melbourne, and then, in 2005, he led the team responsible for the provision of regional air traffic services, including the operation of regional control towers throughout Australia. He was also integrally involved in the implementation of major air traffic management and technology projects, such as the Australia Advanced Air Traffic System known as TAAATS, the evolution of safety management systems and the introduction of user-preferred routes and flex-tracks.
In 2007, Mr Hood joined the Civil Aviation Safety Authority (CASA), where he held the positions of Group General Manager Personnel, Licensing, Education and Training, then Executive Manager Operations.
He returned to Airservices during 2013 to take on the role of General Manager Demand and Capacity Management and was appointed as the Executive General Manager of the Air Traffic Control Group later the same year. In this position, he was responsible for the management of over 1,300 air traffic management staff, providing services for 11 per cent of the world’s total airspace for more than four million flights annually from 28 air traffic control towers and facilities.
Mr Hood is a Fellow of the Royal Aeronautical Society, a Freeman in the Honourable Company of Air Pilots and a Life Member of the Qantas Founders Museum. Until being appointed as ATSB’s Chief Commissioner, he was also a Board Member of Safeskies Australia and, internationally, Vice-Chair of the steering committee for the Civil Air Navigation Services Organisation’s Operations Standing Committee.
He is also a glider and powered aircraft pilot.
A/AA is a not-for-profit and independent association, with an overarching objective to contribute to the long-term health and sustainability of Australia’s aviation and aerospace sector.
Since its launch in 2010, A/AA has developed and delivered many important initiatives and programs to benefit the broader sector in Australia. In this time the organisation has built a national supporter base from industry and government, and has established a significant network of global relationships and formal partnerships.
ATSB Chief Commissioner will once again participate in the Vinnies CEO Sleepout.
The 2018 Canberra/Goulburn Vinnies CEO Sleepout was officially launched on Wednesday 18 April at the National Museum of Australia.
Money raised will provide people experiencing homelessness with vital access to food and accommodation, as well as education, counseling, employment and health services to help people overcome poverty in the long term.
Last year, participants raised $5.6 million nationally, which equates to 1,949,673 individual support programs, 689,819 beds and 1,590,554 meals.
Mr Hood was the highest fundraiser in the ACT and surrounds last year, raising more than $68,000.
Money raised will provide people experiencing homelessness with vital access to food and accommodation.
“It was my first year participating in the CEO Sleepout,” Mr Hood said. “I was shocked to learn that, even here, in the national capital, more than 1700 people face homelessness each day, including an estimated 289 children.
“I was humbled by the number of people – ranging from industry contacts to employees to personal friends – who rallied to help me exceed my fundraising target last year.”
Last year, Canberra CEOs slept out at the Museum of Australian Democracy at Old Parliament House.
“It was the coldest night of any participating location in the country,” Mr Hood said. “It certainly puts homelessness into perspective when you consider that we were all able to sleep in our warm beds the next night.”
This year Canberra/Goulburn participants will sleep at the National Museum of Australia on 21 June.
The ATSB is now producing briefs that describe safety occurrences.
Every year, the ATSB receives up to 17,000 notifications of safety incidents and accidents in the aviation, marine, and rail sectors. They range in significance, from a major accident with loss of life, to incidents with minimal or no damage.
The vast majority of the reported occurrences do not result in an investigation. Instead, information about the occurrences is retained in the ATSB’s databases, which provide a detailed overview of transport safety in Australia that is used for safety data recording, analysis and research.
The ATSB is now using this information to produce Occurrence Briefs – concise reports that detail the facts surrounding an occurrence as provided in the initial notification and from any follow-up information.
ATSB Chief Commissioner Greg Hood said Occurrence Briefs will provide additional opportunities to learn from the experiences of others.
“The Australian transport industry has a very good reporting culture,” Mr Hood said. “While the vast majority of the notifications submitted do not warrant a full ATSB investigation, many of them can still yield useful safety messages.
“These new Occurrence Briefs will allow for greater industry awareness of potential safety issues and possible safety actions.”
Pilots need to know how their aircraft’s avionics and autopilot will react
The investigation into the fatal accident of a Cessna 172S has resulted in the Bureau issuing safety recommendations to the aircraft and autopilot manufacturers about providing limitations, cautions and warnings for autopilot systems and audible pitch trim movement.
The accident occurred on 8 September 2015, when a Cessna 172S was conducting a solo navigation training flight from Point Cook Airfield in Victoria. GPS data later showed the aircraft was on the third leg of the planned journey, cruising at about 3,000 ft above mean sea level, when it started to descend rapidly. The aircraft impacted rising terrain at about 2,200 ft and was destroyed. The pilot, who was the sole occupant, was fatally injured.
The investigation found that it was likely the pilot had manually manipulated the controls while the autopilot was on and engaged in a vertical mode. As a consequence, the autopilot re-trimmed the aircraft against pilot inputs, inducing a nose-down mistrim situation, which led to a rapid descent. The aircraft’s low operating height above the ground, along with rising terrain in front of the aircraft, would have given the pilot limited time to diagnose, react, and recover before impact. The investigation indicates that the pilot may have been unaware of the exact properties of the autopilot.
ATSB Executive Director, Mr Nat Nagy, said that this accident highlighted a matter of serious concern.
“...if automation is not performing as expected, then the safest option under most circumstances is for them to disengage the system...”
“It is now common for general aviation aircraft to be equipped with advanced avionics and autopilot systems,” Mr Nagy said. “And while these systems can be very useful, it is vitally important that pilots understand how the systems will react in different circumstances.”
After the accident, the flight training organisation conducted flight testing and has emphasised to their students the hazard of manually manipulating the flight controls with the autopilot engaged. They have also updated their operations manual to include warnings about the operation and function of the autopilot system - warnings that are absent in the manufacturer’s documentation.
“This is knowledge that all pilots need to possess,” Mr Nagy said. “Pilots should also be aware that if automation is not performing as expected, then the safest option under most circumstances is for them to disengage the system and fly the aircraft manually.”
The ATSB issued recommendations to the aircraft and autopilot manufacturers, calling for them to provide limitation, cautions, and warnings for autopilots and audible pitch trim movement.
