The continuing problem of road users failing to yield to trains at level crossings has been highlighted in the ATSB’s latest investigation into the fatal 2012 accident near Port Germein in South Australia.

The continuing problem of road users failing to yield to trains at level crossings has been highlighted in the ATSB’s latest investigation into the fatal 2012 accident near Port Germein in South Australia.

The accident occurred on 19 March at the Port Flinders Causeway Road level crossing. A Pacific National ore train was travelling on the interstate main line between Port Augusta and Port Pirie. As the train drew closer to the level crossing, it slowed for a temporary speed restriction of 50 km/h. About 200 m from the level crossing, the train driver saw two motor vehicles travelling towards the crossing. He immediately sounded the train’s horn.

The first car, a yellow Hyundai Accent, appeared to be slowing; the train driver sounded the horn a second time just as the vehicle disappeared from his view behind some thick vegetation. As the car re-emerged from behind the vegetation, it looked as if it would stop at the crossing. The train driver sounded the horn a third time, continuously. However, the car continued and entered the level crossing into the path of the train. The train driver made an emergency brake application, but given the train’s closeness to the level crossing and its relative size and weight, it was unable to stop before colliding with the car.

Although they vaguely recalled hearing a horn, they did not relate this to the
approaching train...

The front of the train struck the passenger side of the motor vehicle and then continued to travel around 256 m past the level crossing. The car’s passenger died in the accident and the driver sustained serious injuries. The locomotive crew were shaken but not hurt. The motor vehicle was severely damaged, the train received minor damage. There was little damage to the track and fixed infrastructure.

The driver of the motor vehicle was a local resident and had regularly traversed the level crossing. Although they vaguely recalled hearing a horn, they did not relate this to the approaching train and could recollect little else regarding events prior to the accident.

The level crossing was controlled by passive approach warning signs and a ‘Stop’ sign at the crossing. These required a road user to stop the vehicle at the ‘Stop’ sign and detect the presence of any train through direct visual observation.

The ATSB concluded that the motorist’s attention may have been diverted during a critical period when they would normally have stopped to look for a train.

The ATSB urges all drivers of motor vehicles to be vigilant and obey road traffic signage, especially at level crossings where accidents can easily result in fatalities, serious injuries and extensive damage to infrastructure.

Read the final report: Collision involving a motor vehicle and train 4460S, 10 km south of Port Germein, South Australia, on 19 March 2012

Basic safety preparation before each flight could save your life and, at the very least, speed up your rescue.

An accident involving a Cessna 172N highlights the importance of lodging a Search and Rescue Time (SARTIME) Plan or flight note before flying.

The accident occurred on 7 November 2012, when the pilot of a Cessna 172N crashed his aircraft in a remote paddock near Brisbane while practising for a flight test. The pilot had not submitted a flight plan, nor had he left a flight note with a responsible person or lodged a Search and Rescue Time (SARTIME) with Airservices Australia. The pilot reported having little memory of the flight but said he had planned to fly to the southern training area to practise holding heading and altitude for his upcoming flight test.

Basic safety preparation before each flight could save your life and, at the very least, speed up your rescue.

Following the accident the pilot recalled regaining consciousness and crawling to the aircraft to broadcast a distress call on the aircraft radio. The aircraft was fitted with a personal locator beacon (PLB) but the pilot was unable to locate it after the accident to activate it.

An aircraft in the area reported hearing two faint mayday calls on the Brisbane Centre Frequency. These were not heard by the Brisbane Centre. The area controller requested the pilot of another aircraft in the area to track south from Kagaru to investigate. At about 1410, the crashed Cessna was spotted in a paddock. The pilot was the only person on board and had suffered severe injuries as a result of the accident. The ATSB assessed that the aircraft had been airborne for around 45 minutes, placing the accident about 3 hours before the aircraft was located.

The flight had not been authorised by an instructor prior to the flight. The flying school has now amended their procedures to ensure that no student pilot is provided with aircraft keys before the flight is authorised.

Read the final report: Collision with terrain involving Cessna 172N, VH-JGR, near Kagaru, Queensland, on 7 November 2012

The ATSB continues to emphasise the importance of communication at non-towered aerodromes.

The ATSB continues to emphasise the importance of maintaining effective communication at non-towered aerodromes, after an airspace-related incident involving a Beech 200 Kingair, and an Ag-Cat bi-plane at Swan Hill Aerodrome, Victoria.

The incident occurred on 21 November 2012, when the Kingair was approaching to land on runway 26 at Swan Hill. The pilot had broadcast the aircraft’s position and his intentions both when joining the circuit, and again when turning onto base leg. There was no response. When the Kingair was about 2.7 km from the runway 26 threshold, the pilot noticed a crop-spraying bi-plane, commencing a right descending turn ahead of him, approaching the same runway.

The pilot of the Kingair immediately made a radio broadcast but received no response. The pilot of the Kingair elected to continue the approach, and monitor the biplane carefully. Both aircraft landed safely. 

Communication at non-towered aerodromes is an ongoing safety concern...

The ATSB investigation found that the biplane was not fitted with a radio. The pilot normally maintained a listening watch on a hand-held radio device. However, to avoid damage from the weather and chemicals he removed the hand-held radio when the aircraft was not flying. On this occasion, the pilot had inadvertently left the radio at home. The bi-plane pilot reported conducting a thorough visual check of the runway 26 approach as he joined the circuit, but did not see the Kingair.

Communication at non-towered aerodromes is an ongoing safety concern for the Australian Transport Safety Bureau. ATSB research has found that of the 709 safety occurrences at non-towered aerodromes during 2003–08, 388 were attributed to a breakdown in communication. Safety around non-towered aerodromes has been highlighted in the ATSB’s Safety Watch initiative.

Read the final report: Airspace related event involving Kingair, VH-VAH and Ag-Cat, VH-IFE, Swan Hill Airport, Victoria, on 21 November 2012, which contains more details about the incident and links to useful educational material.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A collision between an empty coal train and excavator at Maitland, NSW shows how clear communication of track workers’ location is vital to ensuring safe work on rail lines.

A collision between an empty coal train and excavator at Maitland, NSW shows how clear communication of track workers’ location is vital to ensuring safe work on rail lines. 

The accident occurred on 20 December 2011 and resulted in extensive damage to the excavator and some damage to the lead locomotive. Neither the crew nor the track workers were injured in the collision. 

Maintenance work on the track had been authorised and safety measures designed to exclude rail traffic from the worksite had been put in place; however, the network controller did not confirm the exact location of the worksite before authorising access to the track for maintenance purposes. There were also communication protocol omissions between the network control and the worksite protection officer and a lack of coordination between interfacing network control officers.  

As a result of the accident the track manager is reviewing safe working rules for Controlled Signal Block arrangements and will ensure that there is coordination between network controllers when a worksite affects more than one controller’s area of responsibility.    

Safe work on railway tracks is a focus for the ATSB’s SafetyWatch initiative that stresses the importance of organisation and effective communication between controllers, crews and track workers.

Read the final report: Collision between a coal train BC151 and an excavator, near Maitland, New South Wales, on 20 December 2011

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

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

Read Martin’s post and contribute to the discussion at: www.atsb.gov.au/infocus

Fatal aircraft accident highlights ongoing risks of flying in poor weather

ATSB investigators have found that the fatal aircraft accident in New South Wales in 2012 was the result of a situation in which many pilots have found themselves: flying into weather conditions that cannot be dealt with. This is a frequent accident risk that the ATSB has been drawing to the attention of Australia’s general aviation community.

The accident occurred on 4 June 2012, as the pilot flew a Cessna 182Q from Walgett to Mudgee. The pilot, the only person on board, was flying under the Visual Flight Rules (VFR), a set of regulations that dictated he could fly only under favourable weather conditions. He had taken off in good weather conditions, and climbed to 5,500 ft. 

From 2006 to 2010, there were 72 such occurrences reported to us, and seven of those resulted in fatal accidents. Fourteen people were killed in these accidents.

During the flight, however, the cloud base lowered, and the pilot descended the aircraft to avoid flying in Instrument Meteorological Conditions (IMC). These are conditions where a pilot has limited visibility and will need to use aircraft instruments to fly safely. The aircraft descended until it was flying about 1,000 ft above flat terrain, either close to or in the cloud. While flying at that level the aircraft crashed into a rock face in mountainous terrain near Tooraweenah, NSW. The pilot died in the accident and the aircraft was destroyed. 

“The issue of pilots who fly into IMC while operating under VFR is an ongoing concern to the ATSB,” said Martin Dolan, Chief Commissioner of the ATSB. “From 2006 to 2010, there were 72 such occurrences reported to us, and seven of those resulted in fatal accidents. Fourteen people were killed in these accidents. Essentially, about one in ten VFR into IMC events results in a fatal outcome.”

The ATSB has been working to educate pilots about the dangers surrounding VFR into IMC. A booklet providing examples and advice on the subject forms part of the ATSB’s well-received Avoidable Accidents series. 

The ATSB’s Avoidable Accidents booklets, including Accidents involving Visual Flight Rules pilots in Instrument Meteorological Conditions, feature case studies on regularly occurring accidents that could have been prevented with good flight management and preparation. The booklets also provide helpful hints and strategies to help pilots stay safe when flying.

Read the final report: Visual Flight Rules in Instrument Meteorological Conditions and controlled flight into terrain involving Cessna 182Q, VH-CWQ, 15 km north of Tooraweenah, New South Wales, on 4 June 2012, which provides links to further resources.

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

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

Short investigations cover incidents and accidents where the associated factors are usually well-understood and do not require more detailed investigations. Nonetheless, each investigation has the potential to produce important Safety Messages for pilots, operators and others in the aviation industry. The investigations also help the ATSB identify statistics and trends in air safety.

The incidents covered in the report include:

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

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

The Australian Transport Safety Bureau is drawing pilots’ attention to the effects of sun-glare when flying, after a Robinson R22 crashed into Lake Marradibbadibba in South Australia.

The Australian Transport Safety Bureau is drawing pilots’ attention to the effects of sun-glare when flying, after a Robinson R22 crashed into Lake Marradibbadibba in South Australia. 

The accident occurred at about 1520 on 31 October 2012. The pilot (the only person on board) had commenced mustering in the helicopter on Innamincka Station at about 0730 that morning. Due to flying low over the sandy and swampy terrain, the helicopter’s windscreen became dirty, leading to poor visibility. During one break, the pilot tried to clean the windscreen with water but this did not improve visibility. 

The accident demonstrates the effect
that sun-glare can have when relying
on visual cues.

The accident happened when the pilot conducted a low-level turn over the edge of the lake and experienced significant sun-glare from the water.  Even though he was wearing sunglasses, the pilot became disoriented due to the sunlight and dirty windscreen. A few seconds later, the helicopter crashed into the surface of the lake and sank rapidly into 2.5 to 3 m of water.

The pilot was not wearing a helmet that day because it was damaged. Nevertheless, he escaped the accident without injury and swam to shore. The helicopter was seriously damaged.  

The accident demonstrates the effect that sun-glare can have when relying on visual cues. In addition, although the pilot was uninjured as a result of this accident, previous ATSB investigations have shown the benefit of wearing a helmet. 

The US Federal Aviation Administration (FAA) has conducted research into sunlight and its association with aviation accidents. A link to that report, along with more details of the accident can be found in the investigation report AO-2012-146.