The ATSB has identified issues with fatigue management after a train passed three signals without taking any action.

The ATSB has identified issues with fatigue management after a train passed three signals without taking any action.

The incident occurred at about 0229 on 30 January 2013, when a work crew was picking up litter on the track at Hurlstone Park. They had arranged for Absolute Signal Blocking (ASB)—a protection measure in which the area controller sets signals at ‘stop’ to prevent rail traffic from entering the affected section. The stop signals are preceded by signals set to ‘caution’, so as to give train drivers enough time to brake and come to a stop at the signal.

At that time, Pacific National freight train 9837 was travelling from Nowra to Orange, crewed by a trainee driver and a more senior co-driver. As the train reached the area of Marrickville, it passed a caution signal but the brakes were not applied as required. Forty seconds later, it passed through a stop signal.

...the ATSB investigation found that the more senior co-driver had inadvertently fallen asleep during the approach to the signals.

Immediately, a visible alert appeared and an alarm sounded at Sydenham signal complex. The area controller broadcast an emergency message ‘9837, stop, stop, stop!’ over the open channel radio to attract the attention of the crew of the train. There was no response. Ten seconds later, the area controller again broadcast the same message, and again there was no response from the train crew.

Meanwhile the work crew picking up litter on the track heard a warning from their lookouts that there was a train coming towards them on the Down Goods line. At this point the train was approximately 300 m away from them. The two members of the work crew on track moved to a safe area behind the platform.

Just before the train passed another stop signal the driver reduced the throttle from power to idle and, shortly after passing the signal, he applied the brakes, bringing the train to a stop.

There had been no injuries or damage, but the ATSB investigation found that the more senior co-driver had inadvertently fallen asleep during the approach to the signals. The trainee driver, in a reduced state of alertness, missed the first signal at caution, and the next signal at stop. He applied the brakes once the train passed the final signal at stop after realising this signal applied to his train.

A number of Pacific National’s policies and procedures were examined to determine if any area of the management or training of the train crew contributed to the incident. Fatigue management, and in particular, over- reliance on the use of bio-mathematical model scores used to roster train crew, was one area where improvement was needed. The ATSB also found that there was an absence of adequate procedures and training for drivers who were performing co-driving duties while coaching trainee drivers.

As a result of the incident Pacific National has undertaken a range of actions to improve its approach to fatigue management and the implementation of fatigue training. They have also commenced a review of ‘signals passed at danger’ risk management processes and training requirements for coach/tutor drivers. A trial has commenced of improved data loggers for the Bulk Rail fleet.

Read the final report: Multiple SPAD by freight train 9837, at Hurlstone Park, New South Wales, on 30 January 2013

A serious incident which saw a glider and a helicopter come too close to each other shows the dangers and responsibilities that exist at Australia’s non-towered aerodromes.

A serious incident which saw a glider and a helicopter come too close to each other shows the dangers and responsibilities that exist at Australia’s non-towered aerodromes.

On 29 June 2013, a Janus glider departed from the Bacchus Marsh aeroplane landing area to conduct a local flight with the pilot and one passenger. At the same time, the pilot of a McDonnell Douglas 500N helicopter was conducting circuits.

The Bacchus Marsh aeroplane landing area is located in uncontrolled airspace and does not have an air traffic control presence. Instead, pilots are responsible for making themselves aware of nearby aircraft and maintaining separation. Key strategies for doing so include making sufficient radio broadcasts so that other pilots know your intention, and maintaining a lookout for other aircraft all times.

As the pilot of the helicopter flew towards the end of the runway from the east, the glider was flying to the same point from the south.

As the pilot of the helicopter flew towards the end of the runway from the east, the glider was flying to the same point from the south. Both pilots had broadcast calls announcing their intentions on the common traffic advisory frequency (CTAF)

As the glider drew near to the end of the runway, the glider-pilot observed the helicopter ahead and below him, approaching the runway. The glider-pilot estimated that the helicopter passed only about 100 ft below the glider. 

Both pilots reported that they had not heard the other’s broadcasts, and the ATSB investigation could not determine why this might have been the case. The Gliding Federation of Australia found that the limited forward and downward view from the rear seat due to the glider’s natural blind spots and the large frame of the front seat occupant may have affected the pilot’s ability to see the helicopter until it was in close proximity.

The issue of safety at non-towered aerodromes is one of the ATSB’s targeted concerns, and forms part of its SafetyWatch warning initiative. A booklet, A pilot’s guide to staying safe in the vicinity of non-towered aerodromes outlines many of the common problems that occur at non-towered aerodromes, and offers useful strategies for pilots to keep themselves and others safe.

Read the final report: Aircraft proximity event between Janus, VH-IZI and MD500N, VH-KXS, Bacchus Marsh (ALA), Victoria, on 29 June 2013

The ATSB is warning pilots of the dangers of flying over water in low visibility conditions...

The ATSB is warning pilots of the dangers of flying over water in low visibility conditions and encouraging pilots to access detailed weather briefings, after four family members died when their aircraft collided with water.

The accident occurred on 1 April 2013, 150 km south-west of Darwin, Northern Territory. A group of pilots were intending to fly various light aircraft from Bullo River homestead to Emkaytee, a private airstrip near Darwin. Their departure was delayed, however, by low cloud. When the group accessed aviation forecasts and weather radar images, they saw that there were isolated thunderstorms, low cloud and rain in the area.

By lunchtime, the weather had lifted at Bullo River, and the weather radar images were indicating improvement along the route. All of the pilots departed between 1300 and 1500, some electing to track via the coast and the rest flying in a more direct route. Among the aircraft was a Cessna 210, carrying a pilot and three family members. That plane would track via the coast.

The group of pilots kept in contact by radio, communicating on a discrete frequency. At about 1510, the pilot of the Cessna 210 reported that he was approaching Cape Ford and the weather ahead was gloomy. He did not sound distressed and at the time no importance was attached to the call. However, that was the last time anyone heard from the Cessna 210.

When the Cessna 210 did not arrive at Emkaytee, search and rescue authorities were notified and some pilots from the group departed in a few aircraft to search the area where the pilot last reported and to check the airstrips in the area.

During the flight from Bullo River to Emkaytee, the pilot continued to track along the planned coastal route towards a thunderstorm, probably encountering conditions such as low cloud, reduced visibility and turbulence, and as a result of one or more of those factors the aircraft descended and collided with water.

Searching in the Cape Ford area was not possible due to continuing storm activity, and fading light forced the return of the search aircraft. The search resumed the next morning until some bodies and a small amount of wreckage from the aircraft were found on the southern part of Anson Bay, about 10 km south-east of Cape Ford. There were no survivors.

The ATSB investigation found that, as the pilot tracked along the planned coastal route, he would have been flying towards a thunderstorm. He would probably have encountered conditions such as low cloud, reduced visibility and turbulence. As a result of one or more of those factors, the aircraft descended and collided with water.

The ATSB is warning pilots of the dangers of flying over water in low visibility conditions and encouraging pilots to access detailed weather briefings, after four family members died when their aircraft collided with water.

When flying in marginal weather conditions, it can be advantageous to track visually via a coastal route. Navigation may be easier, and such a route can ensure an absence of elevated terrain. However, flying over water can mean an increased risk of spatial disorientation when confronted with drastically reduced visibility.

In situations where poor weather is forecast, the ATSB urges pilots to access the Bureau of Meteorology detailed weather briefings to assist with understanding the conditions at the time as well as the immediate trend.

Read the final report: Loss of control and collision with water involving Cessna 210, VH-EFB, 160 km south-west of Darwin, Northern Territory, on 1 April 2013

As it came into land, a Cessna 172N struck a powerline, leaving two people injured and one person dead.

As it came into land, a Cessna 172N struck a powerline, leaving two people injured and one person dead.

The Australian Transport Safety Bureau has released important advice to pilots and the owners of aeroplane landing areas (ALA) after a fatal accident in Victoria.

On 29 October 2012, a Cessna 172N was flying from Coldstream to a private ALA at Bagshot, Victoria, with a pilot and two passengers on board. As the aircraft approached short final on the approach, its nose landing gear contacted a powerline located at the southern end of the airfield.

The powerline significantly reduced the aircraft’s forward speed, sending the Cessna rotating about its nose and impacting the airstrip in an almost inverted attitude. Almost immediately, a fuel-fed fire began at the wing roots. Witnesses assisted the aircraft occupants from the aircraft, however the pilot was seriously injured and the rear seat passenger sustained minor injuries, while the front-seat passenger had died.

The ATSB found that the pilot had been aware of the powerlines, but that his recollection was that they were closer to the tree line in the area leading up to the landing strip. In addition, a lack of adequate warning markings and the fact that the area leading up to the landing strip was mown led him to believe that the entire strip was useable for landing. This perception, combined with the inherent difficulty of visually detecting wires and the distraction of another recently-landed aircraft on the airstrip, reduced the likelihood of his detecting the wire.

There were no high visibility devices attached to the powerlines, nor were any required under the current Australian Standards.

In response to this accident, the owner of the ALA has made significant changes to the runway markings, landing permission procedures affecting operations at the ALA and the available safety and firefighting equipment. In addition, markers have been erected near the powerline.

The ATSB’s investigation report points ALA-owners to resources that can help them manage the risk of collision with obstacles. It also advises pilots to allow themselves sufficient time to make appropriate decision, and urges them to ensure that everyone in their aircraft is wearing seatbelts correctly, affording the best chance of survival in case of an accident.

Read the final report: Wirestrike involving Cessna 172, VH-TKI, 13 km north-east of Bendigo, Victoria, on 29 October 2012

An ATSB research report into stall warning events has given new insights into the way in which Australian pilots respond when flying at the margins of safe flight.

An ATSB research report into stall warning events has given new insights into the way in which Australian pilots respond when flying at the margins of safe flight.

Stall warnings indicate to a flight crew that their aircraft will approach a stall if action is not taken to reduce the aircraft’s angle of attack.

Transport Safety Investigation Regulations require that, if a pilot receives a stall warning, they must report it to the ATSB. There were about 250 stall warnings reported to the ATSB in high-capacity air transport in Australia in the five years between 2008 and 2012.

Stall warnings were found to occur in all flight phases and a range of aircraft configurations...

About 75 per cent of the stall warnings reported to the ATSB were genuine warnings of an approaching stall. In only a minority of cases were system problems reported that resulted in false or spurious stall warnings.

Most stall warnings were associated with stick shaker activations, were momentary in duration, and were associated with thunderstorms, clear air turbulence, sudden wind gusts, or windshear, in both visual and instrument meteorological conditions. As a rate per hours flown, stall warnings were more common in Dash 8, Boeing 767, Boeing 717 and Fokker F100 aircraft, although for the F100, almost all reports were for the aircraft’s stall warning systems activating spuriously. Stall warnings were found to occur in all flight phases and a range of aircraft configurations, not exclusively those related to slow speed, high pitch attitude flight, or flight in poor meteorological conditions.

Read the ATSB research report AR-2012-172

The ATSB has just released a new aviation bulletin containing 13 investigation reports. The Aviation Short Investigation Bulletin Issue 23 covers short, office-based investigations.

The bulletin covers incidents, serious incidents and accidents involving jet aircraft, turboprop aircraft, piston aircraft and helicopters. In some of the occurrences, people suffered minor injuries while some of the aircraft were substantially damaged.

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:

• Abnormal engine indications involving a Boeing 747-438, VH-OJS
• Weather related event involving a Boeing 737, VH-YFF
• Departure from an incorrect intersection involving an Embraer ERJ 190, VH-ZPC
• Two turbulence events involving a Boeing 737, VH-VZY and a Bombardier DHC-8-402, VH-QOP
• Loss of separation between an Airbus A320, VH-VFJ and a Bell 412, VH-VAO
• TCAS event between an ATR72, VH-FVH and a Bombardier DHC-8-315, VH-TQZ
• Turbulence encounter involving a Bombardier DHC-8-402, VH-QOD
• Wheels up landing involving a Cessna 210, VH-ZMT
• Collision on the ground involving a Cessna 172R, VH-IMS
• Power loss involving a Robinson R44, VH-ZON
• Total power loss involving a Bell 47G2A, VH-KHJ
• Hard landing involving a Bell 206B, VH-EPQ
• Loss of control involving a Robinson R22, VH-EGN

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 23

Research report focusses on occurrences over the last ten years, identifying improvements and problems.

The ATSB’s latest research report focusses on aviation safety occurrences over the last ten years, identifying improvements and problems.

Every year, thousands of safety occurrences involving Australian-registered and foreign aircraft are reported to the ATSB by individuals and organisations in Australia’s aviation industry, and by the public. The vast majority are minor, but there are serious incidents and accidents. Each notification is retained in the ATSB’s databases, building up a detailed picture of Australian aviation.

The report describes what accidents and incidents have happened, how often they are happening, and what we can learn from them.

The new ATSB report, Aviation Occurrence Statistics 2003 to 2012, gives that information back to pilots, operators, regulators, and other aviation industry participants. The report describes what accidents and incidents have happened, how often they are happening, and what we can learn from them.

In 2012, there were 107 accidents, 195 serious incidents, and over 7,300 incidents reported to the ATSB involving Australian (VH– registered) aircraft, and a further 570 occurrences that involved foreign-registered aircraft operating within Australia or its airspace. A new addition to this report is data on 274 occurrences involving recreational (non–VH) aircraft safety.

These statistics provide an important reminder to everyone involved in the operation of aircraft that accidents, incidents, and injuries happen more often than is widely believed. Some of the most frequent accident types are preventable, particularly in general aviation.

Read the ATSB research report, AR-2013-067

A research report released today by the ATSB reveals that the vast majority of loss of aircraft separation occurrences in Australia present little or no risk of collision, but more can be done to improve safety.

A research report released today by the ATSB reveals that the vast majority of loss of aircraft separation occurrences in Australia present little or no risk of collision, but more can be done to improve safety. (A loss of separation occurs when two aircraft under air traffic control come closer than a minimum separation distance.)

The report shows that Australia has one of the lowest loss-of-separation occurrence rates, attributable to civilian air traffic control, in the world. A loss of separation (LOS) between aircraft under air traffic control happens on average once every 3 days. In almost 90 per cent of LOS occurrences there was no or a low risk of aircraft colliding. Australia has about six LOS occurrences each year that represent an elevated safety risk. However, a LOS does not normally indicate that there was a near-collision between aircraft. There have been no midair collisions in Australia involving aircraft being provided with a separation service by air traffic control.

The report also reveals that half of all LOS occurrences are attributable to air traffic controller actions, while the other half result from pilot actions. The ATSB considers that more can be done to learn from LOS occurrences attributable to pilot actions in civil airspace.

The number of LOS occurrences under military control was found to be relatively high and most are the result of controller actions. The report finds that current regulatory arrangements do not enable the Civil Aviation Safety Authority (CASA) to give the same level of safety assurance for civilian aircraft under military control as it does for aircraft under civilian control. The ATSB has issued safety recommendations to the Department of Defence and CASA to address the safety issues identified in the report.

The release of this report coincides with the release of two other ATSB investigation reports into separate incidents (one near Ceduna, SA and the other about 900 km northwest of Karratha, WA) that involved losses of separation between passenger aircraft under air traffic control. As part of the Karratha investigation, the ATSB issued two safety recommendations to Airservices Australia. These recommendations were issued in response to the limited formal guidance available on the monitoring of newly endorsed controllers and the use of clearances that allow aircraft to operate anywhere between two flight levels, rather than at a single level.

All three reports are available on the ATSB website.

• AR-2012-034   Breakdown of separation between aircraft in Australia: 2008 to 2011
• AO-2011-144  Breakdown of separation - Boeing 737, VH-VXM and Boeing 737, VH-VUV, near Ceduna Airport, SA, 8 November 2011
• AO-2012-012  Loss of separation between Airbus A320, 9V-TAZ and Airbus A340, A6-EHH near TANEM, 907 km NW of Karratha, WA, 18 January 2012

The ATSB is urging drivers to be vigilant at railway level crossings, to observe road warning signs, obey road rules and look out for trains.

The ATSB is urging drivers to be vigilant at railway level crossings, to observe road warning signs, obey road rules and look out for trains. 

The accident occurred on 19 March 2013 at the Brown Street level crossing in Allansford, Victoria. The El Zorro freight train 9261 was travelling to Warrnambool, Victoria on a scheduled service. 

The level crossing was marked with approach warning signage, road markings and Stop signs for each road approach. Just as the train came to the level crossing, the train’s co-driver, who was seated in the left hand side of the cab, noticed the approaching vehicle. He called out to the train driver to make an emergency brake application. The motor vehicle did not stop at the stop sign, but instead drove onto the level crossing, directly into the path of the freight train, just as the emergency brake was applied. 

The vehicles collided, and the severely damaged motor vehicle came to rest southwest of the level crossing, approximately 33 m from the point of impact. The train continued braking, coming to a stop about 434 m from the level crossing.

The driver of the motor vehicle was fatally injured. Minor damage was sustained by the lead locomotive. There were no injuries to the train crew.

The ATSB found that the south side of the crossing – the direction from which the motor vehicle driver approached the crossing – allowed adequate sighting to the east, the direction from which the train approached. The ATSB concluded that the driver’s familiarity with this crossing, combined with the expectation that a train would not be present due to the low frequency of rail traffic on this line, probably influenced his behaviour.

Warrnambool City Council has temporarily closed the Brown Street Level Crossing until it is equipped with active traffic controls such as lights, bells or boom barriers.

Read the final report: Collision between a motor vehicle and freight train 9261, Brown Street level crossing, Allansford, Victoria, on 19 March 2013

A derailment that spilled about 89 litres of phosphoric acid has shown the critical importance of detecting track defects before they cause an accident.

A derailment that spilled about 89 litres of phosphoric acid has shown the critical importance of detecting track defects before they cause an accident.

The derailment occurred on 9 April 2013, near Lowdina in Tasmania. The train, which consisted of five locomotives hauling 28 wagons, was being operated by a single driver. It had departed Burnie that morning, bound for Boyer in Southern Tasmania. 

A few kilometres away from Lowdina, the track made a tight curve to the left, and as the third wagon travelled over the curve, it came into contact with a twist defect in the rails. The leading wheels of the wagon were jolted off the rails, and the rear wheels derailed a few metres later. 

The train continued on, however, with the driver unaware of the derailment of the third wagon. At Lowdina, the derailed wagon struck a set of points, and the impact completely derailed the third wagon, dragging the fourth and fifth wagons off the tracks. The wagons separated and spilled their containers around the adjacent area. The third wagon was carrying two containers of sodium hydrosulphite while the fourth wagon held a tank of phosphoric acid solution.  

The separation caused the train’s brakes to apply automatically, and it stopped about 90 m later. The driver notified the train control centre and TasRail employees were dispatched to the site. Phosphoric acid was discovered leaking from the top hatch of the tank and a number of spill kits were deployed to contain the leak.

Early detection and conscientious management of track defects is critical in maintaining safe rail operations.

It was estimated that about 89 litres of phosphoric acid escaped from the tank, most of which was contained on site. Eventually, the site was declared safe and investigation/recovery operations began. Approximately 800 steel sleepers were replaced along with about 24 m of rail and associated fasteners and switch gear.

The ATSB investigation identified the large twist defect as the cause of the initial derailment, and found it likely that a previously undetected, small to medium sized twist defect had developed under the passage of the train.  

Prior to this incident, the network owner/manager (TasRail) had identified the need to renew the track infrastructure in the area of the derailment and anticipates that the track between Colebrook and Campania should be renewed by June 2014.

The ATSB emphasises to all rail operators that early detection and conscientious management of track defects is critical in maintaining safe rail operations.

Read the final report: Derailment of train 331, near Lowdina, Tasmania, on 9 April 2013