The ATSB has just released a new aviation bulletin containing 10 investigation reports. The Aviation Short Investigation Bulletin Issue 18 covers short, office-based investigations. 

The bulletin covers incidents, serious incidents and accidents involving jet, turboprop and piston aircraft and helicopters. None of the accidents were fatal; however, some of the aircraft sustained substantial damage and, in some occurrences, people suffered injuries.

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:

• Significant wind change during take-off involving Boeing 737, VH-VZL 
• Aircraft proximity event between a Piper PA-28, VH-PZK and a Cessna 441, VH-VEJ
• Aircraft proximity event between a Beech B200C, VH-AMQ and a Ventus glider, PH-1234
• Aircraft proximity event between a Beech B200C, VH-VAE and an unidentified glider
• Wirestrike involving an Ayres Thrush S2R-T34, VH-HAH
• Power loss (both engines) involving Piper PA-39, VH-RMA
• Aircraft proximity event between a Piper PA-44, VH-MHZ and a Hawker G36, VH-JKL
• Engine failure involving a Cessna 182R, VH-OWZ
• Wheels up landing involving a Cessna 337F, VH-JUP
• Loss of control involving Robinson R22, VH-HGI

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 18

Pilots are being urged to remain focused at all stages of flight following an in-flight distraction that resulted in a fatal accident.

Pilots are being urged to remain focused at all stages of flight following an in-flight distraction that resulted in a fatal accident.

The accident occurred on 4 February 2012 shortly after a Robinson R44 helicopter lifted off from Jaspers Brush Aerodrome, near Nowra in NSW.  

During the lift off, the pilot’s door, which was not securely latched, swung open. The ATSB found that when reaching out to shut the door, the pilot likely let go of the right-hand (cyclic) control. This resulted in the helicopter abruptly pitching nose-up then steeply nose-down. It then rolled to the right and the right landing gear skid and main rotor blades struck the ground. Before the helicopter came to a stop, a fuel-fed fire started around the fuel tanks and lower mast area. Tragically, both occupants of the helicopter died in the accident.

In response to this and a number of other fatal R44 helicopter accidents, the helicopter manufacturer designed rubber bladder-type fuel tanks to replace the original all-aluminium tanks in the R44 and produced a Service Bulletin mandating their fitment.

This was not the first Robinson R44 helicopter accident to result in fatalities from post-impact fire. R44 helicopters which have all-aluminium fuel tanks have proven susceptible to post-accident fuel leaks as a result of an otherwise relatively low-energy impact, increasing the risk of a post-impact fire. In response to this and a number of other fatal R44 helicopter accidents, the helicopter manufacturer designed rubber bladder-type fuel tanks to replace the original all-aluminium tanks in the R44 and produced a Service Bulletin mandating their fitment. The Civil Aviation Safety Authority (CASA) and the ATSB have separately highlighted the safety benefits of retrofitting R44 helicopters with the bladder-type tanks.

The ATSB also issued a Safety Advisory Notice and, following another accident at Bulli Tops, near Wollongong, NSW in which a post-impact fire proved fatal, a Safety Recommendation regarding the dangers of the all-aluminium fuel tanks in the R44. Information on the safety benefits of the installation of bladder-type fuel tanks in the R44 was also circulated through the ATSB’s SafetyWatch web initiative.

Finally, on 29 April 2013 CASA issued an airworthiness directive requiring R44 helicopters fitted with all-aluminium fuel tanks to be retrofitted with bladder-type tanks and clarifying that aircraft being maintained in accordance with the Manufacturer’s Maintenance Schedule are already required to comply with all Robinson Service Bulletins in accordance with Civil Aviation Regulation 42A. More details on airworthiness directive AB/R44/23 can be found at the CASA website.

Read the final report, Loss of control involving Robinson R44 helicopter, VH-COK, Jaspers Brush Aerodrome, New South Wales, on 4 February 2012, on the ATSB website.

R44 accident site at Jaspers Brush, NSW

Robinson R22 helicopter pilots are being reminded to know the limits of their aircraft following the release of the ATSB investigation report into the reliability of the R22 belt drive system.

Robinson R22 helicopter pilots are being reminded to know the limits of their aircraft following the release of the ATSB investigation report into the reliability of the R22 belt drive system. 

The ATSB conducted the investigation in response to several R22 accidents and serious incidents caused by the failure of one or both rotor drive v-belts. Between 2004 and 2012, there were eight occurrences reported to the ATSB. The v-belts are crucial components which transmit engine power to the helicopter's main and tail rotor blades.

Pilots, operators and maintainers should pay particular attention to the installation and condition of R22 drive belts and other components of the drive system.

The report identifies a number of key factors that affect the reliability of the R22 drive belt system. These include:

• flying the aircraft with too much weight on board
• pushing the aircraft’s engine beyond its limits
• failing to maintain the drive system or ensuring the drive sheaves are aligned
• failing to conduct adequate or frequent inspections of the rotor drive system. 

During the investigation, the ATSB issued a safety advisory notice, cautioning Robinson R22 pilots of a drive belt risk and urging them to check their R22 helicopter drive system regularly for misalignment, abnormal wear or other indications of drive belt damage. 

The Robinson R22 helicopter is the most popular light utility helicopter used in Australia and has a reputation for being an extremely reliable machine. As of June 2012, there were over 500 Robinson R22 helicopters on the Australian Civil Aircraft Register. 

Owners and operators should fully appreciate the nature and effects of the operational stresses placed on the helicopter, particularly if the machine is used in a dynamic and demanding way.

Read the full investigation report, AI-2009-038 – Reliability of the Robinson R22 helicopter belt drive system.

ATSB is reminding rail operators of the need for effective inspection regimes and to ensure that rail components meet service requirements.

Following an investigation into the partial separation of an express passenger train, the ATSB is reminding rail operators of the need for effective inspection regimes and to ensure that rail components meet service requirements.

The investigation was initiated in August 2011, after a scheduled Melbourne to Sydney express passenger train (XPT) partially separated as it passed over a dip in the track near Broadmeadows, Victoria. The train suffered a total loss of power and was unable to continue its journey, coasting for a short distance. Initial inspection of the train suggested that the electrical disconnection was a result of the leading power car decoupling from the carriages; but it was clear that the power car and carriages stayed close together because the brake lines remained connected.

The ATSB found that the problem lay in an element of the draft gear (the connecting assembly between cars). The element in question was the tail pin, a steel component 590 mm in length. The tail pin failed as a result of an overstress fracture that was initiated by fatigue cracking – cracking that, worryingly, recent routine ultrasonic testing had not detected. Post-incident material testing established that the mechanical properties of the tail pin were below the required standard.

As a result of the investigation, a new batch of tail pins has been manufactured to an upgraded standard which includes improved quality control and acceptance testing...

Following this incident, the ultrasonic testing procedure was revised to improve the detection of smaller cracks in the tail pin. However, the separation of another XPT near Seymour, Victoria, on 1 August 2012 in similar circumstances showed that the ultrasonic testing regime was still not detecting all fatigue cracks in critical areas of the tail pin.

On 3 August 2012, the ATSB issued a safety issue notice to RailCorp, the operator of the XPT fleet, warning of the preliminary findings. Although this sort of coupler failure was extremely unlikely to lead to a derailment, the consequences of such an event involving a passenger train, should it occur at speed, were potentially very significant. In response, RailCorp set about developing a new testing process and fitting newly designed tail pins.

As a result of the investigation, a new batch of tail pins has been manufactured to an upgraded standard which includes improved quality control and acceptance testing and RailCorp is currently in the process of fitting these new tail pins. RailCorp has also further revised the tail pin inspection regime with the aim of improving its effectiveness.

This investigation did not examine how the idiosyncrasies and condition of the track may have contributed to the partial separation of the train. Those issues will be considered as part of the ATSB’s broader safety issue investigation into the interstate rail line between Melbourne and Sydney.

Read the final report: Partial train separation of XPT ST24, near Broadmeadows, Victoria, on 11 August 2011

Shipping accidents are more frequent than is widely believed but most of these accidents are preventable according to a new ATSB maritime safety report released today.

Shipping accidents are more frequent than is widely believed but most of these accidents are preventable according to a new ATSB maritime safety report released today. 

The report analyses the shipping statistics of accidents and safety incidents involving Australian-registered trading vessels (cargo and passengers) around the world or those involving trading vessels flying foreign flags within Australia’s maritime jurisdictions.

The safety of crew and shipboard workers is a significant concern for the ATSB and is highlighted as a priority in the ATSB’s SafetyWatch initiative.

Between 2005 and 2012, 245 people were killed, missing or seriously injured from reported marine occurrences. In 2012 there were 6 deaths and 33 serious injuries involving crew and shipboard workers. 

Tragically, the ATSB has found that many of these accidents were avoidable. The safety of crew and shipboard workers is a significant concern for the ATSB and is highlighted as a priority in the ATSB’s SafetyWatch initiative.

In 2012, there were 154 marine safety occurrences reported to the ATSB. This was over 50 per cent higher than the 2005–12 average of 100 occurrences each year. The increase in occurrences in 2012 was due to substantial increases in the number of reported ‘incidents’ (137) and ‘serious incidents’ (12). 

Bulk carriers and cargo vessels (including container, roll-on – roll-off cargo, heavy lift and livestock ships) have been the most common vessels involved in occurrences since 2005 and their involvement increased substantially in 2012. There were also increases in the involvement of tankers, offshore support vessels and tugs. 

The number of foreign vessels involved in occurrences grew considerably in 2012. This was predominantly due to an increased involvement in incidents (up 55 per cent on 2011), but there were also more foreign registered vessels involved in serious incidents. The number of Australian registered vessels involved in occurrences also increased in 2012 and the highest number of occurrences recorded was by Australian, Panamanian and Singaporean registered vessels. 

The ATSB is encouraging operators to learn from the experiences of others in the industry to help identify the safety risks in their operation that could lead to a similar accident or serious incident.

Read the full research report, Australian Shipping Occurrence Statistics 2005 to 2012 (MR-2013-002).

The ATSB has just released a new aviation bulletin containing 10 investigation reports. The Aviation Short Investigation Bulletin Issue 17 covers short, office-based investigations. 

The bulletin covers incidents, serious incidents and accidents involving jet, turboprop and piston aircraft and helicopters. None of the accidents were fatal; however, some of the aircraft suffered substantial damage and in one of the occurrences, there were serious injuries.

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:

• Wake turbulence event involving a Boeing 737, VH‑YIO 
• Windshield cracking event involving a Cessna Aircraft 750, VH-RCA 
• Airspace related event involving Beech 1900C, VH-KFN and Aerospatiale AS350 B2, VH-VRW
• Runway loss of separation between Bombardier DHC-8, VH-ZZJ and Aerospatiale, VH-LOJ
• Pilot incapacitation event involving a Hawker B200, VH-FDT
• Loss of separation involving a Cessna 310, VH XXT and a Cessna 210, VH RQD
• Engine failure involving Cirrus SR22, VH-WYH 
• Loss of performance involving DH-82A (Tiger Moth), VH-DDA
• Aircraft proximity event between an Alpha Aviation R2160, VH-NZT and a Diamond DA 40, VH-UNH
• Loss of control involving a Robinson R44, VH-RYO

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 17

A collision between two freight trains at Dry Creek in South Australia has resulted in a rail operator amending its procedures for situations when trainee drivers are under supervision.

A collision between two freight trains at Dry Creek in South Australia has resulted in a rail operator amending its procedures for situations when trainee drivers are under supervision.

The accident occurred on 11 October 2011 as an empty ore train, was being driven by a driver-in-training with a co-driver supervising.  As they proceeded on the interstate main line from Pelican Point to Rankin Dam (near Coober Pedy), the drivers were expecting a clear run without any stops through Dry Creek. The supervising driver was completing an administrative task and the driver-in-training, who was learning the route, became distracted by the headlights of a train ahead, believing it was in an adjoining yard. As a result, they missed an important caution signal, indicating that the train should stop at the next signal.

When the train was about 100 m from the signal, the driver noticed the stop signal. He used the emergency train brake, but passed the stop signal. The train travelled a further 218 m before colliding with the middle of the other train, loaded with grain, which was leaving the interstate main line and entering the adjoining rail yard.

The collision was at low speed and there was no injury to the crew of either train. There was significant damage to the crew cab of the lead locomotive of the ore train and to the grain wagons of the grain train.

Following the accident, the operator amended its procedures to clarify the role and responsibilities of a driver supervising a trainee, and introduced arrangements to inform the supervising driver of the trainee’s level of competency.

Robust procedures that systematically manage the supervision, training and assessment of drivers’ route knowledge are vital for ensuring competency and addressing risks.

Read the final report: Collision between train 1901S and train 5132S, at Dry Creek, South Australia, on 11 October 2011

The ATSB is concerned that a significant number of R44 helicopters are at risk of fire after an accident because their fuel tanks have not been retrofitted with a safety improvement.

The ATSB is concerned that a significant number of R44 helicopters are at risk of fire after an accident because their fuel tanks have not been retrofitted with a safety improvement. 

In its preliminary investigation report, released today, into last month’s fatal R44 helicopter accident at Bulli Tops in NSW, the ATSB highlights the similarities of this accident with others involving R44 helicopters with all-aluminium fuel tanks.

The Bulli Tops accident occurred on 21 March when an R44 helicopter caught fire after striking a tree and colliding with the ground. The pilot and three passengers died in the accident. The circumstances of this accident are consistent with two recent R44 accidents in Australia where the all-aluminium fuel tank ruptured, resulting in a fuel-fed fire after impact. 

The ATSB remains concerned at the significant risk facing many R44 helicopters and has recommended that CASA take further action to ensure compliance with the manufacturer’s service bulletin.

The Robinson Helicopter Company (the R44 manufacturer) had previously issued a service bulletin that requires owners to replace the all-aluminium fuel tank with a bladder-type tank before 30 April 2013. Bladder tanks substantially reduce the risk of a post-impact fire.

Australia’s aviation safety regulator, the Civil Aviation Safety Authority (CASA), confirmed to the ATSB that most owners of R44 helicopters are legally required to replace their fuel tanks before 30 April 2013. Despite this, the ATSB has assessed that about 100 Australian R44 helicopters will not have met the service bulletin by the due date 

The ATSB remains concerned at the significant risk facing many R44 helicopters and has recommended that CASA take further action to ensure compliance with the manufacturer’s service bulletin. CASA subsequently issued an Airworthiness Bulletin reminding registered operators of R44s about their maintenance responsibilities and making it clear that CASA would regard as deficient any system of maintenance that did not include the service bulletin.

The fitment of bladder-type fuel tanks to R44 helicopters is a very important safety enhancement that could save lives. The ATSB has also suggested that regulators and investigation agencies in other countries take note of its preliminary report and consider what steps they can take to increase compliance with the manufacturer’s safety bulletin.

Read the preliminary report: Collision with terrain involving Robinson R44 helicopter, VH-HWQ, at Bulli Tops, near Wollongong, New South Wales, on 21 March 2013

The ATSB’s Chief Commissioner, Martin Dolan, has just published his latest blog post 'Lending a hand overseas'.

The ATSB’s Chief Commissioner, Martin Dolan, has just published his latest blog post. In the post, Martin talks about how the ATSB has helped many countries with their transport safety investigations.

The ATSB has just released a new aviation bulletin containing 10 investigation reports. The Aviation Short Investigation Bulletin Issue 16 covers short, office-based investigations conducted over the past nine months. 

The bulletin covers incidents, serious incidents and accidents involving turboprop and piston aircraft, helicopters, and an incident involving an unmanned aerial system. None of the accidents were fatal; however, some of the aircraft suffered substantial damage and one of them was 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:

• TCAS advisory involving Bombardier DHC-8-315, VH-SBG
• Airspace related event involving Kingair, VH-VAH and Ag-Cat, VH-IFE
• Runway excursion involving Cessna 210N, VH-WPD
• Aircraft proximity event involving a Cessna 172S, VH-VMM and a Schweizer 269C-1, VH-FTR
• Collision with terrain involving Cessna 172N, VH-JGR
• Aircraft proximity event between two Piper PA-28 aircraft, VH-LXH and VH-TAU
• Runway excursion involving Cessna T210, VH-DQI
• Hard landing involving Robinson R44 VH-HYR
• Loss of control involving Robinson R22, VH-HTD
• Airspace incursion involving unmanned airship, Airship 11

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 16