Mr Chris Manning has been appointed to the ATSB Commission with effect 9 March 2015 for a period of three years.
Mr Chris Manning has been appointed to the Australian Transport Safety Bureau (ATSB) Commission with effect 9 March 2015 for a period of three years. He will be the fourth member of the ATSB Commission.
Mr Manning has extensive aviation operational and safety management experience particularly in his former positions as Qantas chief pilot and group general manager of flight operations.
Mr Martin Dolan, the Chief Commissioner has warmly welcomed the appointment saying, ‘I, and the other Commissioners, look forward to working closely with Mr Manning.
‘His experience, particularly in the aviation business, will add considerably to the overall body of knowledge held by the Commission’, said Mr Dolan.
The Minister for Infrastructure and Regional Development, Hon Warren Truss MP made the official announcement via media release on 24 February 2015.
Pilots are advised to use additional cues to identify powerlines, such as the power poles and buildings to which the powerlines may connect.
On 20 September 2014, the pilot of a Piper PA-25 aircraft, conducted a ferry flight from Camden to Bunyan aeroplane landing area, via Goulburn, New South Wales.
After refuelling at Goulburn aerodrome, the pilot tracked to overhead Michelago and continued south towards Bunyan. About 10 km south of Michelago, the pilot intended to overfly a private airstrip to assess its condition and suitability as a potential out-landing site for gliders operating from Bunyan.
The aircraft was heading south and as the airstrip was oriented approximately north-south, the pilot elected to overfly the runway. When about 300 m beyond the runway threshold, the aircraft struck powerlines that crossed the runway about 15 m above ground level, dislodging the windscreen and canopy. The top of the fin was severed by the powerlines. Immediately after the strike, the aircraft banked to the left before returning to level flight. The pilot assessed that the aircraft was too high to land ahead on the remaining runway and made a right turn, initially planning to land towards the north on the adjacent paddock. However, due to the rough surface of the paddock and tailwind, he conducted a short downwind leg before turning to the right, and the aircraft landed into wind on the runway.
The top of the fin was severed by the powerlines.
The ability of pilots to detect powerlines depends on the physical characteristics of the powerline and the effect of weather conditions. Powerlines may be invisible to the naked eye. When flying at low altitude, pilots should use additional cues to identify powerlines, such as the power poles and buildings to which the powerlines may connect.
Safety message
Research conducted by the ATSB found that 166 aircraft wirestrikes were reported to the ATSB between July 2003 and mid-June 2011 and another 101 occurred and were unreported but identified by electricity distribution and transmission companies. The majority of wirestrike occurrences were associated with aerial agriculture operations however, 22 occurrences (8 per cent) involved private operations. See the research report AR-2011-004: Under reporting of aviation wirestrikes.
Depending on the environmental conditions, powerlines may not be contrasted against the surrounding environment. Often the wires will blend into the background vegetation and cannot be recognised. In addition, the wire itself can be beyond the resolving power of the eye: that is, the size of the wire and limitations of the eye can mean that it is actually impossible to see the wire. As such, pilots are taught to use additional cues to identify powerlines, such as the associated clearings or easements in trees or fields that can underlie the powerline, or the power poles and buildings to which the powerlines may connect.
Risks associated with operations to private airstrips can be mitigated by ALA owners assessing their airstrips against the guidance in CAAP 92-1(1) Guidelines for aeroplane landing areas. Such risk assessments would benefit from giving consideration to first time users of the ALA.
Pilots need to consider the effect of an in-flight engine failure at different altitudes has on the time available to manage that failure and identify a suitable forced landing area.
On 31 May 2014 at about 1322 Western Standard Time, a Beech Aircraft Corp D17-S, was being used to conduct a private flight from Crooked Brook landing area to Geraldton airport, Western Australia. The flight was conducted in visual meteorological conditions and the pilot was the only person on board.
After departure, the pilot tracked FNS in a northerly direction and climbed to an altitude of about 2,500 feet above mean sea level (AMSL). About a minute after setting the engine to cruise power, the pilot felt a violent vibration with an associated decrease in engine power. The pilot described the engine as ‘surging’ and ‘back-firing’. The pilot conducted initial troubleshooting and was unable to identify a reason for the engine malfunction. The vibration ceased and the engine was no longer producing power but the propeller was windmilling. The pilot elected to leave the landing gear retracted and set up a glide approach tracking to the north-east to locate a more suitable landing area to conduct a forced landing. A suitable paddock was identified that was near a house. The aircraft flew over a line of tall trees and then clipped a fence that was next to a private road leading to the house, went through a second fence on the other side of the road, which partially arrested the aircraft. It then impacted a large log and came to rest. A passer-by assisted the pilot to evacuate the aircraft. The pilot was seriously injured and transported to hospital and the aircraft was substantially damaged.
This accident is a timely reminder for pilots to consider the effect an in-flight engine failure at different altitudes has on the time available to manage that failure and identify a suitable forced landing area.
The pilot reported that he had conducted a pre-take-off brief covering the actions and considerations in relation to an engine failure. The pilot also indicated that he had flight planned to cruise at an altitude of 4,500 feet AMSL but amended this to 2,500 feet AMSL due to the increase in wind speed at altitude.
The pilot reported that the engine was subsequently examined and that a hole was located in the number five cylinder wall. Extensive internal damage was found and the reason for the internal engine failure could not be determined. The pilot indicated that the engine had failed at about 223 hours since it was last overhauled and that the specified time between engine overhauls was 1,000 hours.
Safety message
Pilots should consider the effect an in-flight engine failure at different altitudes has on the time available to manage that failure and identify a suitable forced landing area. In this instance the pilot had enough time to manoeuvre towards a different area.
pre-flight decision making and planning for emergencies and abnormal situations for the particular aerodrome including a thorough pre-flight self-brief covering the different emergency scenarios.
conducting a thorough pre-flight and engine ground run to identify any issues that may lead to an engine failure.
taking positive action and maintaining aircraft control either when turning back to the aerodrome or conducting a forced landing until on the ground, while being aware of flare energy and aircraft stall speeds.
Issue 38: The ATSB has just released a new aviation bulletin containing 10 investigation reports.
The Aviation Short Investigation Bulletin covers a range of the ATSB’s short investigations and highlights valuable safety lessons for pilots, operators and safety managers.
Released periodically, the Bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken. The Bulletin also highlights important Safety Messages for the broader aviation community, drawing on earlier ATSB investigations and research.
Issue 38 of the Bulletin features 10 safety investigations:
This incident highlights the importance of thorough pre-flight planning and monitoring and reassessing actual versus planned flight tracks and aircraft fuel consumption.
The pilot of a Cessna 206 aircraft conducted a solo training flight from Bankstown to Cootamundra, New South Wales and return. At about 0800 Australian Eastern Daylight Time, the aircraft departed Bankstown Airport with full fuel and landed at Cootamundra Airport at about 0943.
After taxiing to the parking bay and shutting down the engine, the pilot dipped the fuel tanks. He reported that 100 litres remained in the right tank and 85 litres in the left. This indicated an actual fuel consumption rate of about 67-70 litres/hour, and about 12 litres less fuel remaining in the tanks than the pilot had expected.
...about 7 litres of fuel (unusable) remained in the right tank and none in the left.
At about 1022, the aircraft departed Cootamundra on a planned track to Bankstown via Rugby and Bindook. At about 1100, the pilot observed that the aircraft had deviated from the planned track and attempted to track direct to Bindook, however took up a heading of about 120°, which resulted in a further deviation from the planned track.
At about 1114, and at 5,500 feet above ground level, the aircraft’s engine surged and then stopped. The pilot conducted some emergency checks and sighted a suitable landing area. The aircraft collided with trees about 50 metres short of the intended landing site and was substantially damaged. The pilot sustained a minor injury.
The aircraft owners attended the accident site and reported that about 7 litres of fuel (unusable) remained in the right tank and none in the left. This incident highlights the importance of thorough pre-flight planning and monitoring and reassessing actual versus planned flight tracks and aircraft fuel consumption.
The train crew believed that the impact had derailed the locomotive and they were about to fall off the bridge and into the Katherine River.
Risks are not confined to the road vehicle and occupants – there is also a high likelihood of train derailment after any track collision, with significant associated risks to the train crew, passengers, freight and infrastructure.
On 12 October 2014, Train 7MD3 (comprising two locomotives, crew car and 78 wagons loaded with manganese ore) struck a utility road vehicle, at a speed of about 70 km/h, on a track near the Katherine River Bridge in the Northern Territory.
While the road vehicle became lodged under the lead bogie, the locomotive and the trailing wagons remained on track. The train travelled approximately 500 m further before finally coming to rest atop a culvert bridge, with the damaged vehicle hanging precariously over the right side of the bridge.
This occurrence highlights the very significant risk of injury, death and serious damage that is associated with road vehicle operators attempting to cross railway tracks in areas other than designated level crossings.
The co-driver contacted Train Control and reported the collision while the driver went to the crew car to ensure the wellbeing of the other train crew before all three returned to the lead locomotive. One of the crew inspected the road vehicle and ascertained that no one was trapped inside.
Northern Territory Police officers attended the scene and provided assistance to all four crew members. Neither the driver of the vehicle nor any of the train crew was injured in the collision, although one member of the train crew was taken to hospital as a precautionary measure. All crew members were relieved from duty. The driver of the vehicle was interviewed by the Northern Territory Police. During the interview, the driver informed the interviewing officers that he had been attempting to traverse the track just west of town when his car became stuck. Upon realising the approach of a train he had attempted to warn the train by flashing a torch.
The ATSB found that The ARTC’s inspection and maintenance practices were ineffective at identifying and correcting the deteriorating condition of track infrastructure exhibiting accelerated wear, such as 38A points at Spencer Junction.
On 17 February 2013, ore train 9614S was departing Spencer Junction en route to Whyalla, South Australia. While the train was traversing 38A points at the northern end of Spencer Junction, the driver noticed a change in the train’s dynamic behaviour and immediately reduced the throttle.
The train then quickly came to a stop due to the automatic application of the electronically controlled pneumatic train brake. Upon inspection of the train, the second driver discovered five ore wagons were derailed.
The ARTC’s inspection and maintenance practices were ineffective at identifying and correcting the deteriorating condition of track infrastructure exhibiting accelerated wear, such as 38A points at Spencer Junction.
The ATSB’s investigation found that the leading edge of the right hand 38A point blade was worn and damaged. The blade damage had created a ramping angle, allowing the lead wheel of the ore wagon to “ride up” the blade and derail. The derailed wheels then impacted and damaged the concrete sleepers, which ultimately failed to maintain track gauge and allowed further wagons to derail. During the derailment sequence, a rupture to the train’s electronic control pneumatic pipe initiated the application of the train brake.
The ATSB found that the Australian Rail Track Corporation’s inspection and maintenance regime, following two similar derailments at the same location, had not been sufficient to identify and remediate the deteriorating condition of the 38A points, and ultimately contributed to the derailment.
In the months leading up to this derailment, Genesee Wyoming Australia (GWA) and the Australian Rail Track Corporation (ARTC) had agreed to a rail upgrade programme which included a new turnout incorporating 38A points, using 60 kg rail laid on concrete bearers. At the time of this derailment, a new turnout had been prepared, but had not yet been installed. Upgrade works have since been completed.
Following installation of the upgraded infrastructure, more frequent monitoring for wear rates of the point blade(s) was undertaken. After several months of condition monitoring it became evident that track performance and wear rates could be managed as specified in the Code of Practice and the normal inspection schedule was reinstated.
Safety message
Track infrastructure owners and maintainers should consider the associated increase in wear on track infrastructure when there is an increase in the volume of rail vehicles being operated. The high dynamic forces that may be exerted from rail vehicles, specifically those that bear a heavy axle load, will accelerate the rate of wear on track infrastructure.
In these circumstances, increased inspection and maintenance of track components should be considered until it can be established that resulting wear rates can be adequately managed in accordance with the established standards.
The ATSB found that the network control officer had established a standard-gauge route beyond signal DYN158 rather than the required broad-gauge route.
The Pacific National broad-gauge freight train, No. 9204V, was travelling from Warrnambool to Appleton Dock, Victoria. Due to track works at West Footscray Junction—to repair damage arising from a previous derailment—the train was despatched from Tottenham Yard toward the port via an alternative route, the adjacent dual-gauge Main line.
Track circuit failures resulting from the track damage meant that Up-direction Home signals on the Main line were displaying Stop indications, and for this reason the train had departed Tottenham yard on the authority of a Signalman’s Caution Order. The locomotive crew received two further Caution Orders en-route, the last of these being for Home signal DYN158.
Signal DYN158 protected a turnout that provided for a diverge of the standard-gauge line away from the broad-gauge, and the network control officer (NCO) had inadvertently set this turnout for a standard-gauge movement. The locomotive crew proceeded past the Home signal and through the points, resulting in derailment of the locomotive and one wagon at low speed.
The ATSB has recommended that ARTC undertakes further action to address the risk of directing trains onto incorrect gauge track in dual-gauge territory.
The ATSB found that the NCO had established a standard-gauge route beyond signal DYN158 rather than the required broad-gauge route. Although the Train Control System software incorporated an on-screen gauge alarm to warn an NCO against setting an unviable route, in this instance that screen alert did not appear, since its generation was contingent on the gauge detection system that was not functioning. The signalling system had been degraded as a result of a previous derailment.
The Train Control System permitted the NCO to establish a route on an incorrect gauge for train 9204 and displayed that route as viable.
ARTC has introduced provisions to ensure that modifications made to the Phoenix Train Control System display are fully understood by Control Centre staff, and has also modified the Signalman’s Caution Order form to provide explicitly for the checking of the intended route and for the train crew to check the setting of points to be traversed.
The ATSB has recommended that ARTC undertakes further action to address the risk of directing trains onto incorrect gauge track in dual-gauge territory.
Safety message
When the signalling system and the functionality of safety intervention devices is degraded and an alternative process of safeworking is in use, there is a need for a heightened level of awareness and caution on the part of network control officers and train crew.
When designing control system safety mechanisms, such as the Gauge Alarm in this instance, the rail operator should consider all possible sub-system failures to ensure the intervention remains effective under all circumstances.
Flying at night in remote areas without sufficient visual cues continues to be one of the most dangerous forms of flying, as evidenced by a recent fatal accident in Western Australia’s Kimberley region.
Flying at night in remote areas without sufficient visual cues continues to be one of the most dangerous forms of flying, as evidenced by a recent fatal accident in Western Australia’s Kimberley region.
An ATSB investigation into the accident found the pilot of an R22 helicopter, who did not hold a night visual flight rules (VFR) rating or instrument rating, continued flying after last light to try to reach Springvale station.
The lack of local ground lighting on a moonless night meant the pilot had no visual cues to know exactly where the helicopter was going or reliably control its attitude, and collided with terrain 46km short of the intended destination.
Night flying continues to pose a high risk for many pilots, particularly those in remote areas where there is little to no ground lighting. On average there are two accidents a year that occur from visual flight at night.
“We continue to be concerned about the frequency of accidents – many fatal – that involve pilots flying with reduced visual cues,” said ATSB Chief Commissioner Martin Dolan.
“Based on research from other countries, accidents at night tend to be unforgiving and more likely to lead to death.”
In the 20 years between 1993 and 2012 there were 26 accidents in Australia that occurred in visual (night) conditions. There were also another 10 accidents involving inadvertent VFR flight into 'instrument meteorological conditions', such as poor weather or cloud. Those 36 accidents resulted in 58 deaths. Nearly all of the accidents occurred on dark nights.
“This fatal accident in the Kimberley highlights the inherent high risk of night flying in remote areas,” Mr Dolan said.
For pilots, the ATSB’s message is simple.
“Day VFR pilots need to plan to arrive at their destination at least 10 minutes before last light and to have a realistic ‘Plan B’ to use when it becomes apparent that an intended flight cannot be completed in daylight,” Mr Dolan said.
“It is important, also, for operators and others involved in the operation of aircraft to actively support safety-first pilot decision-making.”
An important safety message
Flying with reduced visual cues is one of the ATSB’s nine SafetyWatch priorities.
Under visual flight rules (VFR), it is crucial pilots have sufficient visual reference to see and avoid obstacles. Visual cues are also required to maintain orientation so VFR pilots know which way is up and can maintain control of their aircraft. There are often less visual cues at night, even though visibility may be good.
The ATSB has just released a new aviation bulletin containing 9 investigation reports. Issue 37
The Aviation Short Investigation Bulletin covers a range of the ATSB’s short investigations and highlights valuable safety lessons for pilots, operators and safety managers.
Released periodically, the Bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken. The Bulletin also highlights important Safety Messages for the broader aviation community, drawing on earlier ATSB investigations and research.
Issue 37 of the Bulletin features 9 safety investigations:
