The ATSB is urging drivers to show caution after an accident in Victoria destroyed a dog trailer being towed by a truck and caused significant damage to a locomotive and 75 m of track infrastructure.

The ATSB is urging drivers to show caution after an accident in Victoria destroyed a dog trailer being towed by a truck and caused significant damage to a locomotive and 75 m of track infrastructure.

The accident occurred on 7 September 2013 at the Pettavel Road level crossing at Mount Moriac, 20 km west of Geelong. A V/Line passenger train was operating the scheduled service from Melbourne to Warrnambool, Victoria. As the train approached the level crossing, two trucks that were transporting soil from a development site turned onto Pettavel Road. The Pettavel Road level crossing was equipped with approach warning signage and Stop signs for each road approach.

The locomotive came to a stand about 315 m past the level crossing. Five passengers, the locomotive driver and a conductor sustained minor injuries in the collision.

The train driver saw the trucks approaching and sounded the whistle multiple times. As the train drew closer to the crossing, the train driver decided that the trucks may not have been alerted to the train’s approach and applied the emergency brakes and braced for the collision.

The leading truck drove through the level crossing and the second truck, a rigid truck and dog trailer combination followed. As the second truck passed through the crossing the locomotive, which had decelerated to a speed of about 101 km/h, collided with the truck’s dog trailer, which was carrying about 12 cubic metres of soil.

The locomotive came to a stand about 315 m past the level crossing. Five passengers, the locomotive driver and a conductor sustained minor injuries in the collision. The truck driver was not injured, but the collision destroyed the dog trailer, and caused significant damage to the locomotive and approximately 75 m of track infrastructure.

This accident is a reminder for all road vehicle drivers, especially of heavy vehicles, using railway level crossings equipped with passive controls need to be vigilant, observe road-warning signs, obey road rules and look out for trains.

Read the final report: Collision between a truck and passenger train 8205, Pettavel Road, Mount Moriac, Victoria, on 7 September 2013

A severe-turbulence incident involving a Boeing 767 shows why it’s crucial to safely stow all carry-on baggage, including laptops and iPads, during flight.

A severe-turbulence incident involving a Boeing 767 shows why it’s crucial to securely stow all carry-on baggage, including laptops and iPads, during flight.

On 8 November 2013, the Boeing 767 experienced severe turbulence while descending into Sydney. The turbulence lasted for about 2 minutes and the crew discontinued the approach and initiated a go-around. During the climb of the go-around, the aircraft experienced more turbulence, and one passenger sustained a serious head injury from a laptop computer that fell from an overhead locker. Another received a rib injury and a third was injured by an iPad.

After circling for about 20 minutes, a further attempt to land was affected by turbulence. The crew declared a PAN and diverted to Williamtown, New South Wales. After landing safely, the injured passengers were transported to hospital for treatment.

This incident is a timely reminder for passengers to stow all carry-on baggage securely in the overhead lockers...

Before departure from Melbourne, weather reports had only indicated the possibility of moderate turbulence below 5,000 ft. After the incident, the Bureau of Meteorology reported that a strong and gusty south-westerly change had produced windshear as the change encountered the north-easterly sea-breeze. This sudden change affected the landing.

This incident is a timely reminder for passengers to stow all carry-on baggage (including laptops and iPads) securely in the overhead lockers or under the seat in front of them, especially when the seatbelt sign is turned on. These items can become projectiles during turbulence if not properly secured.  

The ATSB’s Aviation Safety Bulletin Staying Safe against In-flight Turbulence identified that 99 per cent of people on board an aircraft receive no injuries during a typical turbulence event. However, in recent research, the ATSB is seeing a doubling of turbulence and windshear events in passenger operations, some affecting the safety of those in the cabin.

Read the final report: Turbulence event involving a Boeing 767, VH-OGU, near Sydney Airport, New South Wales, on 8 November 2013

The ATSB has just released a new aviation bulletin containing 9 investigation reports. The Aviation Short Investigation Bulletin Issue 26 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 26 of the Bulletin features 9 safety investigations:

• Loss of separation assurance between an Airbus A320, VH-VNQ and Boeing 737, VH-VZB
• Incorrect configuration involving Airbus A320, VH-FNP
• Flight planning related event involving an Airbus A330, VH-QPD
• Turbulence event involving a Boeing 767, VH-OGU
• Fuel related event involving a Fairchild SA227, VH-UUO
• Electrical system event involving a Cirrus SR22T, VH-LBQ
• Aircraft proximity event between a Piper PA-44, VH-CZH and a Mooney M20, VH-DJU
• Loss of control involving a Eurocopter EC-120B, VH-VMT
• Aircraft proximity event between a Bell 206, VH-WCS and a PZL Bielsko 51, VH-XOP

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 26

Transport aircraft operators are being encouraged to review crew guidance to ensure the risk of windshear associated with thunderstorms and dry microbursts is effectively managed.

Transport aircraft operators are being encouraged to review crew guidance to ensure the risk of windshear associated with thunderstorms and dry microbursts is effectively managed.

This advice follows the 19 October 2012 hard landing of a Fokker F100 aircraft at Nifty Aerodrome in the Pilbara region of Western Australia.

While the flight crew were positioning the aircraft for a 5 NM (9 km) straight-in approach into a slight headwind, they received a windshear caution. In response, the crew increased the approach speed and extended the speed brake to stabilise the approach. The approach continued and apart from a few minor speed variances, the conditions seemed relatively benign.

The ATSB found that when the aircraft was on approach to land at about 80 ft above ground level the flight path almost certainly coincided with a strong outflow of a dry microburst.

As the aircraft was in the final stages of the approach and descending from 80 ft to 30 ft above ground level, the airspeed dropped from 133 kt to 110 kt and the rate of descent increased to about 1,000 ft/min. The loss of airspeed occurred over a period of 3 seconds and by touchdown, the aircraft was being affected by a 32kt tailwind.

The aircraft touched down on the runway threshold, almost 300 m short of the normal touchdown point, and bounced. The high rate of descent resulted in a hard landing with significant damage to the aircraft. None of the crew or passengers were injured.

The ATSB found that when the aircraft was on approach to land at about 80 ft above ground level the flight path almost certainly coincided with a strong outflow of a dry microburst. A dry microburst is a column of rapidly descending air that can produce damaging and divergent winds when it reaches the ground. They are initiated by evaporative cooling and are generally associated with high-based cumulous cloud. The scale and suddenness of a microburst makes it a great danger to aircraft.  This resulted in a performance-decreasing windshear that led to the serious drop in airspeed, high sink rate, undershoot and a hard landing.

As a result of the occurrence, the operator sought to improve the weather information available at aerodromes serviced by their F100 fleet and modified its simulator training program along with consolidation of the windshear procedures and guidance. The operator also provided additional guidance in the use of the flap following receipt of a windshear caution during approach and planned to introduce a new threat-based take-off and landing briefing model.

Read the final report: Windshear-related hard landing involving Fokker 100, VH-NQE, Nifty Aerodrome, Western Australia, on 19 October 2012

A collision with a passenger train at a level crossing sent a utility vehicle spinning off the track, leaving the motorist seriously injured.

A collision with a passenger train at a level crossing sent a utility vehicle spinning off the track, leaving the motorist seriously injured.

The ATSB is once again warning the drivers of motor vehicles to be vigilant at railway level crossings after an accident in Inverleigh, Victoria.

The accident occurred on 31 August 2013, when the passenger train known as The Overland was travelling from Melbourne to Adelaide. At around 10.00 am, as the train approached the Mahers Road level crossing at Inverleigh (about 27 km west of North Geelong), the level crossing flashing lights, bells and boom barriers began to operate.

The Overland was travelling at 78 km/h, with its headlight illuminated. As it drew near to the level crossing, the crew saw a Holden Rodeo dual cab utility travelling along an unsealed maintenance access track adjacent to the railway.

This accident highlights the need for road and rail authorities to work together in maintaining the integrity of fences and structures to exclude public access to the railway corridor.

The utility continued along the access track and then, to the train crew’s surprise, it entered Mahers road and turned into the lowered level crossing boom barrier, striking the end of the boom. The utility came to a stand across the railway line.

The train driver made an emergency brake application, but the train could not be stopped in time and collided with the front of the utility. The utility was spun around, and it came to a rest on the side of the track. The train stopped about 370 m beyond the level crossing. The sole occupant of the utility was seriously injured and transferred to Royal Melbourne Hospital. The locomotive crew suffered from shock, but none of the train’s 103 passengers were injured.

The ATSB investigation found that the road used by the utility, known locally as the ‘Gallagher Road Extension’ was, in fact, a railway maintenance access track located entirely within the railway corridor on land leased by the Australian Rail Track Corporation. Nevertheless, many commercial mapping providers, including VicRoads, had incorrectly identified the maintenance access track as a road. It was regularly used by local traffic, but since it was not a public road, there were no level crossing traffic control devices (flashing lights or road signage) provided.

This accident highlights the need for road and rail authorities to work together in maintaining the integrity of fences and structures to exclude public access to the railway corridor. In the wake of this accident, the Australian Rail Track Corporation and the Golden Plains Shire have advised that they will work together to isolate the rail corridor from Gallagher Road permanently.

Read the final report: Level crossing collision between passenger train 7MA8 and a dual cab utility, Inverleigh, Victoria, on 31 August 2013

A runway incursion between a Fairchild SA227 and a Bell 47G helicopter at Ballina Airport is a timely reminder that to stay safe around non-controlled aerodromes, pilots need to monitor and broadcast on the CTAF and maintain a good lookout.

A runway incursion between a Fairchild SA227 and a Bell 47G helicopter at Ballina Airport is a timely reminder that to stay safe around non-controlled aerodromes, pilots need to monitor and broadcast on the CTAF and maintain a good lookout.

On 9 October 2013 the helicopter was conducting circuit training with an instructor and a student pilot on board. The Fairchild was about to commence its take-off. After broadcasting a lining-up and rolling call, which was acknowledged by another pilot inbound to Ballina, the pilot of the Fairchild commenced the take-off run. Just before rotation he saw the helicopter stopped on the runway towards the departure end. The Fairchild pilot increased the climb angle to maintain separation.

The helicopter instructor attempted to contact the Fairchild with no response received. She then realised that the radio volume had been turned down.

The Fairchild pilot had expected the helicopter to be conducting left-hand (not right-hand) circuits and for the helicopter to be in the air, not on the runway. After lining up, his attention had been directed inside the cockpit before commencing the take-off run.

The helicopter instructor commented that it was the end of a long hot day. She said they had been making calls on the CTAF but did not hear any broadcasts from other aircraft. While this might have indicated a radio problem, it was not unusual to have low traffic volume at Ballina at the time. Because the student was a commercial pilot, the instructor had not been monitoring the pilot’s actions as closely as she would with a low-hour student. Ballina has an aerodrome frequency response unit (AFRU) which provides an automatic response when transmitting on the CTAF. Because the radio volume was turned down the ‘beep backs’ from the system would not have been heard.

Following the incident, the operator of the Fairchild advised that they would be highlighting the importance of communication and situational awareness for all pilots. The helicopter operator advised that they would introduce a requirement into the start-up checklist for the pilot to check the automatic weather information service (AWIS). As well as providing weather information, this would enable the pilot to confirm that the radio is on and is audible.

The ATSB’s publication A pilot's guide to staying safe in the vicinity of non-towered aerodromes contains useful advice and is available from the ATSB website.  

The ATSB SafetyWatch highlights the broad safety concerns Safety around non-controlled aerodromes.

Read the final report: Runway incursion between a Fairchild SA227, VH-UZP and a Bell 47, VH-UTF, at Ballina Airport, New South Wales, on 9 October 2013

Rail operators are being reminded of the need to report Category A rail occurrences to the ATSB.

Rail operators are being reminded of the need to report Category A rail occurrences to the Australian Transport Safety Bureau (ATSB) following a number of incidents that have not been reported as required.

Recent reforms to national rail safety legislation have resulted in changes to the way rail occurrences need to be reported in some states and territories. By law, rail transport operators in South Australia, Northern Territory, Tasmania and New South Wales must now verbally report Category A incidents to the ATSB.

A review of reports received by the ATSB, and the Office of the National Rail Safety Regulator (ONRSR) has shown inconsistencies in reporting patterns. In particular:

• some Category A notifiable occurrences are being reported in written form to the ONRSR only with no verbal report to the ATSB
• some Category A notifiable occurrences have been incorrectly classified by operators as Category B and only reported to the ONRSR.

The ATSB and ONRSR remind all operators in these states and the Northern Territory of their responsibilities under the law and that failing to report category A occurrences to the ATSB may incur a penalty. 

All Rail Safety National Law (RNSL) occurrences resulting in serious injury are classified 
Category A 
and only those accidents that result in hospital admission should be reported.

The ONRSR also reminds operators that under the rail national safety law, a running line derailment is a Category A occurrence. (A number of such occurrences have not been reported to the ATSB.)

All Rail Safety National Law (RNSL) occurrences resulting in serious injury are classified Category A and only those accidents that result in hospital admission should be reported (against this category).

The ATSB and ONRSR have released a fact sheet to help operators better understand their reporting responsibilities.

• Fact sheet: Reporting Cat A rail occurrences to the ATSB

The ATSB is reminding pilots to recognise the implications of abnormal engine indications, after a helicopter lost power in mid-air.

The ATSB is reminding pilots to recognise the implications of abnormal engine indications, after a helicopter lost power in mid-air.

On 13 November 2013, the pilot of a Robinson R22 helicopter was conducting aerial mustering on a property about 155 km SSW of Normanton, Queensland. The helicopter was hovering behind a mob of cattle when the pilot felt the helicopter jerking. He landed and conducted a magneto check (magnetos are a component of the ignition system). He selected the left magneto and the engine rapidly lost power. He then selected the right magneto and the engine ran normally. He reselected the magneto switch to ‘both’ and attempted to get in contact with the property manager.

This accident highlights the importance of understanding the implications of abnormal engine indications.

Unable to make contact with the manager, he elected to take off. Once airborne, he was able to communicate with the manager via the ultra-high frequency radio. He turned the helicopter towards a road and commenced an approach to land on the road. At about 20 ft above ground level, however, the engine stopped. The pilot lowered the collective and flared the helicopter for landing. On impact, the helicopter spun around 180º. The helicopter was substantially damaged, but the pilot was uninjured.

An engineering inspection of the left magneto revealed that the distributor bushing was loose, resulting in 6 mm of movement in the plastic gear wheel. As a result, the magneto was providing the ignition spark to an incorrect engine cylinder at the wrong time.

This accident highlights the importance of understanding the implications of abnormal engine indications.

The Robinson R22 Pilot Operating Handbook advises pilots that, when a magneto malfunction is suspected in-flight, select the magnetos to the BOTH position and land as soon as practical.

Read the final report: Total power loss involving a Robinson R22, VH-STK, 155 km south-south-west of Normanton Aerodrome, Queensland, on 13 November 2013

A wheels-up landing of a Beech 95-B55 is an important reminder that, when faced with an unexpected equipment malfunction, the most important priority should be to fly the aircraft.

A wheels-up landing of a Beech 95-B55 is an important reminder that, when faced with an unexpected equipment malfunction, the most important priority should be to fly the aircraft.

On 20 October 2013, the pilot was preparing for a flight from St Helens Airport, Tasmania. He reported that he closed the aircraft door and noted a distinctive click, indicating that the door was secure. He then completed the taxi and pre-take-off checks and noted that everything was operating normally.

The pilot commenced the take-off and as the aircraft became airborne at about 60 ft above ground level, the door opened. Documents blew out of the door and around the cockpit. The pilot continued the climb to 1,000 ft in preparation to return for landing. He could not recall retracting the landing gear after take-off.

The ATSB has identified 325 occurrences between 1997 and 2004 that involved distractions.

When on the downwind leg of the circuit, the pilot tried to close the door but could not reach it. On turning onto base leg the pilot selected 10 degrees flap and continued the approach. On final, he selected full flap and reduced the throttle setting to idle for landing. As he touched down, the pilot realised the landing gear was retracted. The aircraft slid along the runway and came to rest 600 m from the runway end. It was substantially damaged. The pilot recalled hearing a horn activate during the landing but was unable to distinguish whether it was a stall warning or the landing gear warning horn.  

The pilot commented that he normally lowered the landing gear on the downwind leg [or on downwind], but omitted to do so on this occasion. He had never heard the landing gear warning before and was not aware what it sounded like. He normally used memorised checks but resolved that, in future, he would use written checks. An engineering inspection found the door appeared to be twisted and not sitting flush, though it was lockable. About 9 years earlier the door had opened on take-off but had since been repaired by engineers.

The ATSB has identified 325 occurrences between 1997 and 2004 that involved distractions. The source of distraction for the majority (where a source could be established) related to equipment problems, including five involving doors opening. The Flight Safety Foundation recommends that, after a distraction source has been identified, the next priority should be to re-establish situational awareness by conducting the following:

• Identify: What was I doing?
• Ask: Where was I distracted?
• Decide/act: What decision or action shall I take to get back on track?

The report has links to publications containing further information on pilot distraction.

Read the final report: Wheels-up landing involving Beech Baron aircraft, VH-TLP, at St. Helens Airport, Tasmania, on 20 October 2013

Track workers take evasive action as an oncoming train unknowingly approaches their worksite.

Track workers take evasive action as an oncoming train unknowingly approaches their worksite.

The issue of safe work on rail in Australia continues to be a matter of serious concern for the ATSB after a ‘safeworking irregularity’ near Glenrowan resulted in a near miss between track workers and a V/Line passenger train.

The incident occurred on 29 October 2013, when the Australian Rail Track Corporation (ARTC) was undertaking ballast remediation and drainage maintenance on the bidirectional track between Benalla and Wangaratta, Victoria. The work was being done on the west track, but worksite protection was put in place on both the west and east tracks, with flagmen and Audible Track Warning signals (ATWs) placed either side of the worksite. The west track was designated ‘Absolute Occupation’, ensuring that no trains could use it, while ‘Track Force Protection’ was put on the east track, so that the workers would be made aware of any approaching train well before it arrived.

Safe work on rail continues to be a matter of serious concern for the ATSB.

The worksite at Glenrowan used two radio channels for communications. One channel was used for safety critical communication between the flagmen and the track force coordinator, the second was used for worksite communication between the track workers, including the track force coordinator. The track workers relied on the track force coordinator for safety critical communication since they had no direct communication with the flagmen.

At approximately 0730, V/Line passenger train 8610, travelling between Albury and Melbourne on the east track, stopped at Wangaratta to pick up passengers. The track force coordinator at Glenrowan was made aware of the train and instructed the flagmen to remove the ATWs and allow the train to pass the work site unrestricted. This was done without informing the work site supervisor or any of the track workers.

At about 0744, the outer flagman observed train 8610 and contacted the inner flagman to let her know that the train was approaching. The inner flagman attempted to contact the track force coordinator multiple times, but did not get a response. The track force coordinator was in conversation with the work site supervisor and not within earshot of either of his radios. The inner flagman then tried to alert the track force coordinator by whistle, but without success.

At about the same time, the work site supervisor observed train 8610 approaching and called out ‘Train on!’ on the work site radio.

The track workers also saw the train and took action to ensure that they and their machines were clear of the east track. The driver of Train 8610 did not notice anything unusual as the train passed through the worksite (without incident) at about 0746.

After the incident, the work site supervisor took control of the site. The track force coordinator was tested for the presence of alcohol or other drugs which proved negative.

As a result of this occurrence, the ARTC held a post-incident meeting with all relevant personnel to discuss the incident and reinforce the necessity to follow procedures when providing track protection. The program manager instructed all site personnel that ATWs were to be left on track to warn of trains approaching worksites.

The ARTC has also provided follow-up training and recertification regarding the relevant network safeworking rules.

The issue of safe work on rail in Australia is a major concern for the ATSB. The ATSB has investigated several accidents that have occurred when maintenance work was being carried out on or near railway tracks. The issue forms parts of the SafetyWatch initiative, which provides warnings and strategies to help transport workers keep themselves safer.

Read the final report: Safeworking irregularity, at Glenrowan, Victoria, on 29 October 2013