A coastal pilot disembarking from the chemical tanker Golden Concord fell 3 m to the deck of a pilot launch when the pilot ladder manrope he was holding appeared to give way.

A coastal pilot disembarking from the chemical tanker Golden Concord fell 3 m to the deck of a pilot launch when the pilot ladder manrope he was holding appeared to give way.  

Pilot transfers by way of pilot ladders are routine, yet inherently risky operations. They require the correct configuration of the pilot ladder and manropes and clear and standardised communication between the ship’s crew, the pilot and the pilot launch crew.

Fortunately, in this case the pilot did not sustain any serious injuries. However, the ATSB found a number of risk controls designed to prevent such an occurrence had been compromised.

Following this incident, the ship’s management company has revised its pilot transfer procedures to ensure that all transfers are conducted with a deck party consisting of a supervising officer and at least one deck rating. The company has also revised its procedures to ensure that pilot ladders and manropes are rigged in accordance with the most recent international requirements.     

The pilotage company has revised its procedures to incorporate the provision of information about the use of manropes to pilot launch crews on their approach to the ship. Pilots and launch deckhands are now required to conduct a visual and manual check of pilot ladders before disembarking. The company is also reinforcing the importance of adhering to the standard communication protocols specified in the safety management system.

Read the final report: Fall from the pilot ladder on board the chemical tanker Golden Concord, Goods Island, Torres Strait, Queensland, on 4 July 2013

An aircraft separation incident between an UAV and crop duster highlights the challenges with having a diverse mix of aircraft operating in the same airspace.

An aircraft separation incident between an unmanned aerial vehicle and crop duster highlights the challenges with having a diverse mix of aircraft operating in the same airspace.

On 12 September 2013 the pilot of an Ayres S2R commenced aerial agricultural spraying operations on a property near Horsham, Victoria. At about the same time, the operator of a UAV, Sensefly eBee 178, arrived at ‘Iluka Echo’ (Echo) mine site to conduct an aerial photography survey of the site. After completing his pre-flight preparation and risk assessment of the operation, the operator heard an aircraft operating about 1 – 1.5 km away on a neighbouring property.

Pilots of UAVs are required to operate at or below 400 ft but approval can be granted to operate higher...

The UAV operator broadcast on the area frequency advising his intention to conduct unmanned aerial photography operations over the Echo mine site but did not receive a response. He then asked the mine manager to contact the farmer, who was loading fertiliser into the hopper of the Ayres aircraft to advise him of the UAV operating in the area and advise the pilot.

The UAV then commenced operations. After completing the first load of fertiliser the pilot of the Ayres aircraft reported that the farmer informed him that there would be an ‘aircraft’ conducting aerial photography over the mine site, near one of the areas he would be operating on. The pilot assumed that this would be a fixed-wing aircraft operating at or above 500 ft AGL. Accordingly, he intended to remain at or below 350 ft to ensure separation.

During their operations the two aircraft came within 100 m of each other. The pilot of the Ayres reported that he did not see the UAV at any time, although he was aware of a white vehicle parked on the road. He was not aware of the procedures for UAV operations. The UAV operator advised that in future, even if unable to contact the pilot via radio, he would ensure he spoke directly to the pilot of any aircraft operating in the same area as the UAV. This would assist in increasing awareness and understanding of UAV operations.

Pilots of UAVs are required to operate at or below 400 ft but approval can be granted to operate higher—in this case a NOTAM would be issued (A NOTAM is a notice filed with Airservices to alert other pilots of potential hazards.) All UAV operators are also required to broadcast on the appropriate frequency. Pilots and operators need to remain vigilant and employ ‘see and avoid’ principles and they need to recognise that small UAVs may be difficult to see.

Read the final report: Aircraft separation issues involving an Ayres S2R, VH-WBK and an unmanned aerial vehicle, 37 km south-south-west of Horsham Airport, Victoria, on 12 September 2013

The ATSB has just released a new aviation bulletin containing 11 investigation reports. The Aviation Short Investigation Bulletin Issue 28 covers short, office-based investigations.

The bulletin covers incidents, serious incidents and accidents involving jet, turboprop and piston aircraft, as well as helicopters.

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.

Issue 28 of the Bulletin features 11 safety investigations:

• Turbulence event involving a Boeing 777, VH-VPE
• Runway excursion involving a Fairchild SA226, VH-OGX
• Hard landing involving a Grob G 115C2, VH-ZIV
• Take off event involving a De Havilland DH-82 Tiger Moth, VH-RAY
• Loss of control involving a Piper PA-28R 201, VH-HVX
• Pilot incapacitation involving a Piper PA 28-180, VH-PXB
• Aircraft proximity event between a Cessna 172S, VH-FPV, and a Piper PA 28-161, VH-OWO
• Near collision between a Piper PA-25, VH-MLS, and an AMS-flight DG-303, VH-DGA
• Loss of separation between a Schweizer 269C, VH-HYD and a Piper PA-31, VH-IBI
• Engine failure involving a Eurocopter EC120B, VH-JYV
• Controlled flight into terrain involving a Robinson R22, VH-LZR

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 28

An Airbus A320-232 descended below two minimum safe altitudes.

An Airbus A320-232 descended below two minimum safe altitudes.

The ATSB reminds operators and flight crew of the vital importance of continuous attention to active and armed auto-flight system modes. This reminder comes after an incident which occurred on 16 July 2012 as an Airbus A320-232, operated by Jetstar Airways, was arriving at Queenstown International Airport, New Zealand.

The aircraft was conducting an instrument approach to runway 05 using the aircraft auto-flight system. The approach consisted of a series of progressively lower steps that signified the minimum safe altitude for each segment of the procedure.

The crew intended to select an auto-flight system mode during descent that would have ensured compliance with procedure minimum safe altitudes, but overlooked that selection. As a result, the aircraft continued descent in an unintended mode that did not prevent infringement of minimum safe altitudes. The aircraft consequently descended beneath the minimum safe altitude of two segments of the approach procedure. Upon recognising the descent profile problem, the crew climbed the aircraft to intercept the correct path and continued the approach to land safely.

The ATSB found that the crew were not strictly adhering to the operator’s sterile flight deck procedures...

Although the aircraft was below the minimum safe altitude during two segments of the approach, a collision with terrain was never likely given the fine and clear in-flight conditions. No Ground Proximity Warning System alerts were generated during the incident.

The ATSB found that the crew were not strictly adhering to the operator’s sterile flight deck procedures, which restrict flight deck conversation during the safety-critical and high workload phases of flight to important operational matters. This probably allowed the crew to become distracted and not notice that descent was continuing in an unintended auto-flight system mode. Also, the operator’s procedures did not specifically draw the crew’s attention to unchanged auto-flight system modes during descent.

Following this occurrence, the operator included additional guidance material in its Flight Crew Training Manual regarding mode awareness. It also included a warning on its Queenstown approach charts.

It is important that crews continually monitor descent profiles in relation to approach procedure minimum safe altitudes, irrespective of any expectation that the descent is being appropriately managed by the auto-flight system. This occurrence also highlights the importance of robust auto-flight system management procedures.

Read the final report: Descent below segment minimum safe altitudes involving Airbus A320-232, VH-VQA, near Queenstown, New Zealand, on 16 July 2012

A weak track formation contributed to the derailment of six train wagons and damage to 15 km of track, according to a new ATSB report.

A weak track formation contributed to the derailment of six train wagons and damage to 15 km of track, according to a new ATSB report.

The derailment of the freight train 7SP5 occurred between Caragabal and Wirrinya, NSW on 23 October 2011.

At the time of the derailment, the train was travelling from Stockinbingal towards Parkes and was 14 hours into its journey from Sydney to Perth. The lead bogie (the undercarriage with wheels) of the 42nd wagon of the train derailed three kilometres north of Caragabal. The wheels of the bogie were dragged, off the rails, for about 15 km until they reached a turnout where six wagons separated from the train and overturned.

A dip in the track, combined with an adverse twist, caused the bogie to derail.

The ATSB found that a dip in the track, combined with an adverse twist, had caused the bogie to derail. Based on available evidence, it is likely that the track dip developed under train 7SP5 and was caused by an undetected weakness in the track formation. (The formation is the foundation of the track structure.) Track inspections had been conducted, but it is unlikely that the inspections would have identified any warning signs of formation weakness before the derailment.

Maintenance history indicated that track geometry defects had been identified and repaired around the site of the derailment, but they were generally not significant when compared to the defect that caused the derailment and defects identified and rectified in other locations along this track. Since this serious incident, the Australian Rail Track Corporation (ARTC) has implemented its Engineering Code of Practice for its rail network in NSW as part of an ongoing program of procedure standardisation across the ARTC rail network. The ATSB has urged managers and maintainers of track infrastructure to strengthen their predictive track maintenance systems by considering greater examination of historical maintenance and defect data.

Read the final report: Derailment of train 7SP5, between Caragabal and Wirrinya, New South Wales, on 23 October 2011

Over the recent summer months, the ATSB has seen an unprecedented increase in turbulence events.

The Australian Transport Safety Bureau’s monitoring of the latest aviation events has revealed a significant increase in the number of weather-related occurrences involving high-capacity air transport aircraft.

“We are seeing a doubling of turbulence and windshear events in passenger operations,” said Dr Stuart Godley, head of the ATSB’s Aviation Safety Research team. “And some of those events are affecting the safety of those in the cabin.”

The number of turbulence and windshear related occurrences involving high-capacity aircraft was significantly above the 5-year historical average.

Turbulence is caused by the irregular movement of air, and often cannot be seen. When air masses with different speeds, direction or temperatures meet each other, turbulence is likely to occur. While turbulence is normal and occurs frequently, it can be dangerous. 

The ATSB found that, from October to December of 2013, the number of turbulence and windshear related occurrences involving high-capacity aircraft was significantly above the 5-year historical average, and had actually doubled compared to the previous three months.

“Because they’re weather-related, these events are cyclical,” explained Dr Godley. “We’re used to seeing more of them in the summer, but this increase is unprecedented. We’re especially concerned because there is a correlation between these events and cabin safety issues, especially cabin injuries due to turbulence.”

In fact, turbulence is the leading cause of in-flight injuries to passengers and cabin crew. To help passengers understand turbulence and keep themselves safer, the ATSB has produced a booklet, Staying Safe against In-flight Turbulence, which is available for free download.

On 28 August 2013, at 1:30 in the morning, the pilot of a Fairchild SA227 took off from Brisbane for Bankstown, only to find the right wing of the aircraft dropping markedly.

There had been issues with the aircraft’s fuel balance earlier in the day, and the left fuel quantity gauge had been identified as unserviceable, but the pilot had believed that the imbalance issue had been addressed. Clearly, that was not the case.

Thankfully, the weather was fine and the night was bright, and the pilot was able to establish a visual reference and maintain control of the aircraft. He raised the right wing, and opened the fuel cross-flow valve to rebalance the aircraft. After about two minutes, the aircraft was rebalanced, and he closed the cross-flow valve. The aircraft continued to handle normally during the flight until the descent when, at about 400 ft above ground level, the right wing suddenly dropped again. The pilot raised the right wing and elected to continue the approach, landing without further incident.

This incident has demonstrated the importance of thorough pre-flight preparation in particular with regard to fuel planning and loading.

The events that led up to this dangerous situation were characterised by a series of miscommunications and assumptions. Earlier that day, the aircraft had been flown from Cairns to Brisbane. The pilot of that flight (who would not be flying the aircraft on its next leg) had advised the engineering staff that the fuel tanks were out of balance and the left fuel quantity gauge was unserviceable. The pilot and engineers rebalanced the fuel tanks in accordance with the company procedures.

The pilot of the next flight then requested that additional fuel be uploaded due to the forecast weather at Bankstown.  A staff member, noting the recorded imbalance and unaware that the previous pilot and engineers had corrected the problem, placed more fuel in the right tank, once more bringing the aircraft out of balance.

When it came time for the pilot to establish the fuel quantities, he could not use the fuel gauge, and so he made the calculation using information from the fuel log and the remaining fuel gauge. The additional fuel and the company’s procedures for estimating fuel, however, resulted in the pilot unknowingly taking off with a fuel imbalance of 100 L between the tanks.

This incident has demonstrated the importance of thorough pre-flight preparation in particular with regard to fuel planning and loading. As a result of the occurrence, the aircraft operator is instituting several safety actions to ensure that there will be no repetition of the circumstances which could have so easily turned disastrous.

Read the ATSB investigation report, AO-2013-196 for information and strategies on ensuring fuel safety.

Rail operators are being encouraged to use independent data validation systems, such as forward facing video, on trains.

Rail operators are being encouraged to use independent data validation systems, such as forward facing video, on trains, after an ATSB investigation into a signal irregularity could not substantiate the observations of the train crew.

The braking distance for freight trains can be significant so train drivers must begin braking well in advance of a projected stopping point. As a result, train drivers need advance information about the status of fixed signals ahead of the train movement.

The incident occurred on 7 April 2013, as a southbound freight train was travelling at 115 km/h on the main line of the Culcairn North passing loop in New South Wales. The train consisted of four locomotives hauling 37 wagons having a total length of 1,489 m and a trailing mass of 2,561 t.

The ATSB encourages all rail operators to consider the use of independent data validation systems, such as forward facing video on trains...

The driver and second person of the train would later report that, as they approached a signal designated DIS-CN03, it was displaying a clear (green) indication. As a result, they expected that the next signal, CN03, would be at ‘proceed’ and that the track ahead would be clear of any opposing train. After passing signal DIS-CN03 and rounding a sweeping right hand curve, however, the driver saw the headlight of an opposing train and that home signal CN03 was set at ‘stop’ (red).

The driver immediately made an emergency brake application to stop the train, which averted a collision with the opposing train. There were no injuries or damage as a result of this occurrence.

The ATSB investigation of the available evidence showed that the signalling system was operating correctly at the time of the incident and therefore the signal (DIS-CN03) preceding the signal at stop (CN03) should have been displaying a caution aspect (yellow). However, the crew were adamant that the signal DIS-CN03 had been at green.

As the train was not fitted with forward facing video equipment, the ATSB was unable to substantiate the train crew’s observations of signal DIS-CN03.

The Australian Transport Safety Bureau encourages all rail operators to consider the use of independent data validation systems, such as forward facing video on trains, to provide a source of information to assist in coming to an understanding of rail occurrence events, such as signal irregularities.

Read the final report: Signal irregularity reported by crew of train 5BM7, Culcairn North, New South Wales, on 7 April 2013

Owners of certain ships are being warned of a dangerous drainage system modification that contributed to the death of an engineer.

Owners of certain ships are being warned of a dangerous drainage system modification that contributed to the death of an engineer.

The accident occurred on 20 March 2013, on board the bulk carrier Nireas. The ship was anchored off Gladstone, Queensland, and an engineer was carrying out the routine task of draining water from the ship’s main air receiver (part of the compressed air system). Unbeknownst to the engineer, as he continued with his task the pressure from the air receiver was affecting another component, the drainage pot. The drainage pot was a heavy steel cylinder mounted into the deck adjacent to the air receivers. The pressure built within the pot until, eventually, the drainage pot observation window exploded. Tragically, the engineer was killed by flying debris.

The ship builder contacted all owners of ships in which it had fitted this design of drain system to warn them.

The ATSB investigation found that the original designers of the system had assumed that it would be open to the atmosphere. The modifications to the design, however, had created a closed system, allowing the pressure to affect the drainage pot. The shipyard had not ensured that the new design was adequately engineered, tested and approved prior to installation, despite having procedures in place which should have ensured such scrutiny. 

Furthermore, the ATSB learned that similar designs of drainage systems had been, and continued to be, fitted in ships by various shipyards around the world.

In response to the accident, the ATSB issued a safety advisory notice to all classification societies, advising them of the accident and its safety implications. The ship builder contacted all owners of ships in which it had fitted this design of drain system to warn them. They informed them of the accident and requested that all observation glasses be removed and for the pots to remain unobstructed.

The Australian Maritime Safety Authority issued a Marine Notice to draw industry attention to this accident and its causes.

This accident highlights the need to follow a formal process of risk assessment when considering possible equipment modifications. Such a process must ensure that all associated risks are identified, considered and appropriately treated.

Read the final report: Crew member fatality on board the bulk carrier Nireas, while at anchor off Gladstone, Queensland, on 20 March 2013

Papua New Guinea continues to strengthen aviation safety with 12 Papua New Guineans completing training to international standards in air accident reporting.

Papua New Guinea continues to strengthen aviation safety with 12 Papua New Guineans completing training to international standards in air accident reporting.

The training course, jointly run by the PNG Accident Investigation Commission (AIC) and the ATSB, covered the preparation of aviation accident and serious incident reports that meet international standards. The ATSB has been working closely with the PNG AIC to conduct a series of training courses for PNG citizens working in the aviation industry.

The Australian Government shares a partnership goal with PNG of improving aviation services to comply with international safety and security services. The 12 PNG aviation professionals from the public sector and from private aviation operators undertook a five-day course in air accident reporting that began on 10 February at the Air Nuigini Training Centre at Jackson’s Airport, Port Moresby.

Through the PNG Australia Transport Sector Support Program, Australia assists PNG to improve aviation through a diverse range of initiatives.

Conducted by a former ATSB Director, Alan Stray, the course explained International Civil Aviation Organization (ICAO) requirements for accident and serious incident reporting. Through a series of practical examples, participants built their knowledge and skills to prepare accident and incident reports that meet international standards and support improvements in aviation safety in PNG.

The participants, including three women, worked hard and saw the challenging course as a boost to their career prospects. Ms Bessie Andrew of PNG Air Services said, ‘I was so pleased to see other women participants. Accident report writing requires attention to detail and well-developed analytical skills. I feel that this is a great career opportunity for women in PNG.

The Minister for Civil Aviation, the Hon Mr Davis Stephen recognised the training to ICAO standards and presented certificates in a ceremony on 14 February 2014.

Future training courses will cover Safety at Accident Sites and Aircraft Accident Investigation Fundamentals. 

Through the PNG Australia Transport Sector Support Program, Australia assists PNG to improve aviation through a diverse range of initiatives.

Course participants included public sector and private aviation operators

 Ms Jean Mose, manager quality and safety at Airlines PNG, receives her certificate of completion from Civil Aviation Minister Steven Davies