Three important lessons have emerged from the ATSB’s investigation into the capsize of the tug Adonis at Gladstone, Qld in June 2011

Three important lessons have emerged from the ATSB’s investigation into the capsize of the tug Adonis at Gladstone, Qld on 11 June 2011:

• Masters of tugs, regardless of size, need to be actively aware of the signs that a tug might be in danger of capsizing and what to do to lessen this danger. 
• In multiple tug operations, masters need to plan the passage and consider the speed of the passage and when it is time to release the towline. 
• It is also essential that masters communicate frequently throughout the passage bring any concerns about speed to the other master’s attention. 

On 11 June the harbour tug Adonis, which had four persons on board, was engaged in an operation with a second tug, Wolli, to move an Australian registered unmanned steel flattop dumb barge (Chrysus) in the port of Gladstone, Queensland. Adonis capsized during the operation. Three of the four persons on board escaped but the fourth drowned in the wheelhouse. 

The tug’s crew were not able to release the towline using the towing hook’s quick release arrangement before the tug capsized.

The ATSB found that while the masters of the two tugs were aware of the risk of capsize, neither of them realised that Adonis had entered a classic capsize scenario when it moved abaft of the barge’s port bow before the barge had begun to slow down. The barge’s speed was not reduced in time to allow Adonis’s master to regain control of the tug and manoeuvre it back into a safe position ahead of the barge. The tug’s crew were not able to release the towline using the towing hook’s quick release arrangement before the tug capsized. 

Investigations into the accident found that the retrospective fitting of a set of ‘H’ bitts to the tug aft of the towing hook had a detrimental effect on the tug’s manoeuvrability. The fitting of the ‘H’ bitts and a towing winch also resulted in Adonis being unstable when undertaking towing operations over the stern. This fact was never identified by the tug’s owners because the tug’s stability was not recalculated after the fitting of the additional equipment. 

Sea Swift, the owners of Adonis, have produced new procedures covering the quick release arrangements on its tugs and enhanced the training and familiarisation of its crews with these arrangements. The company has also reviewed all of its tugs’ towing and quick release arrangements and introduced regular testing of the equipment. They have also implemented a program to review all stability data for tugs purchased overseas. Sea Swift has also employed an experienced training manager to review and monitor the company’s health and safety practices. A review of Sea Swift’s training assessment for new masters has extended the period of training to include mentoring and supernumerary runs with other masters to develop a greater understanding of towing requirements.   

Read the final report: Capsize of the Australian registered tug Adonis, at Gladstone, Queensland, on 11 June 2011

Air traffic control (ATC) local procedures need to be unambiguous and encompass all possible operational circumstances. That is the safety message arising from the loss of separation north of Cairns in November 2011.

Air traffic control (ATC) local procedures need to be unambiguous and encompass all possible operational circumstances. That is the safety message arising from the loss of separation between a Cessna 402C and a Cessna C210 that occurred 6 km north of Cairns, Queensland on 23 November 2011. Effective radar navigation guidance is also important when positioning an aircraft for an approach. 

The C402 was conducting an instrument landing system (ILS) approach for runway 15 at Cairns airport and was 1.8 NM (3.3 km) from the airport when the pilot initiated a missed approach from a height of 1,000 feet in instrument meteorological conditions. At the time, the C210 was on the same ILS approach and was 6.4 NM (11.9 km) behind the C402. About 1 minute after the pilot turned left to establish the aircraft on the missed approach track, the distance between the two aircraft reduced below the required ATC separation standard.

Airservices has amended the local procedure to assist with the clarity and intent...

The ATSB identified that a local ATC procedure published, in part, to assist ATC in separation management during a missed approach event, was not clear and was subject to varying interpretations. This resulted in the spacing between the aircraft being closer than intended when the pilot of the C402 commenced the missed approach. The local procedure did not fully consider all operational aspects that could lead a pilot to initiate a missed approach in instrument meteorological conditions above the procedure-defined minimum cloud base height. 

In response to this occurrence, Airservices has amended the local procedure to assist with the clarity and intent and to enforce minimum flow (distance) spacing, and has updated controller missed approach procedures refresher training. The updated training will increase controller awareness of separation assurance issues relating to consecutive approaches and ensure that controllers give due consideration to the broad range of aircraft types using straight-in approaches. 

Read the final report: Loss of separation between VH-TFK and VH-PDP, 6 km north of Cairns, Queensland, on 23 November 2011

Pilots must provide accurate and complete information on their medical questionnaire and seek medical advice for any condition that could affect their ability to fly safely.

• Pilots should seek the advice of a Designated Aviation Medical Examiner (DAME) if they become aware of any condition that could affect their ability to safely carry out the privileges of their aviation licence.

On 3 September 2011 the pilot and one crewman in a Robinson R-44 helicopter departed an airstrip located near the Kumarina roadhouse, approximately 150 km south of Newman, Western Australia.

The crew were conducting low-level geophysical survey operations when the pilot was observed to have slumped forward in the seat. The crewman, who was seated behind the pilot, made unsuccessful attempts to rouse the pilot. The helicopter subsequently impacted terrain causing significant injuries to the crewman and the pilot. After the impact the pilot regained consciousness but died of his injuries before medical help arrived.

Pilots must provide accurate and complete information on their medical questionnaire and seek medical advice for any condition that could affect their ability to fly safely. 

The ATSB found that the pilot held a Class 1 Aviation Medical Certificate with no restrictions despite inconsistencies in recorded information in the pilot’s aviation medical questionnaires and one previous unconsciousness episode being recorded. If the correct information had been documented, further medical tests may have been required and the results used to better assess the pilot’s medical status.

During the investigation, CASA was advised of the reporting inconsistencies in the pilot’s aviation medical questionnaires. In response, CASA confirmed that the medical section of its website is being reviewed and guidance material on medical issue reporting requirements will be available on the website when the work is complete.

In addition to regular aviation medical assessments, pilots should seek the advice of a Designated Aviation Medical Examiner (DAME) if they become aware of any condition that could affect their ability to safely carry out the privileges of their aviation licence. It is also important for pilots to check the information documented in their aviation medical assessment for accuracy and completeness to allow for accurate assessment of their medical status and any risk to the safety of flight.

Read the final report: Pilot incapacitation while operating a Robinson R44, VH-HCA, 180 km south-south-west of Newman, Western Australia, on 3 September 2011

On 21 January 2013 the ATSB welcomed a delegation from the Republic of the Union of Myanmar. The delegation includes officials from the Myanmar Department of Civil Aviation and the Myanmar Aircraft Accident Investigation Bureau, and representatives from airlines within Myanmar.

On 21 January 2013 the ATSB welcomed a delegation from the Republic of the Union of Myanmar. The delegation includes officials from the Myanmar Department of Civil Aviation and the Myanmar Aircraft Accident Investigation Bureau, and representatives from airlines within Myanmar.

The Australian Transport Safety Bureau is providing specialist assistance to Myanmar with its accident investigation into a Fokker 100 jet that crashed on 25 December 2012. The jet, carrying 71 people, including 5 Australians, landed in a field short of the runway at Heho Airport, which is the portal to the popular tourist destination of Inle Lake. There were fog patches in the area at the time.  Two persons were killed, one a passenger in the plane and the other, a motorcyclist on the ground. The plane was badly damaged when its wings were shorn off and it caught fire. Ten passengers required hospital treatment and a further 26 were taken to hospital for medical checks.

The ATSB’s assistance involves the provision of technical specialists and facilities in Canberra to download and decode data from the aircraft’s flight data recorder and the cockpit voice recorder (commonly referred to as black boxes). This assistance is underpinned in Annex 13 to the Convention on International Civil Aviation, which promotes cooperation between member States internationally and details the protocols to facilitate the provision of such assistance.

Providing such assistance is also consistent with the Minister for Infrastructure and Transport’s statement of expectations of the ATSB that includes the requirement that, subject to available resources, we provide assistance to accident investigations in other countries, in accordance with international protocols. Under these arrangements, Australia provides assistance widely in the Asia-Pacific region and has assisted countries such as New Zealand, Papua-New Guinea and Indonesia, as well as other Pacific Island states.

The ATSB welcomes the opportunity to work with our counterparts in the region. It is hoped that the ATSB’s work will provide significant assistance to the Myanmar investigation and contribute more broadly to the enhancement of aviation safety internationally. These opportunities also provide a valuable means by which the ATSB can develop and exercise the skills and experience of its own specialist investigators.

The ATSB’s Chief Commissioner, Martin Dolan, has just published his latest blog post.

• ATSB Chief Commissioner Martin Dolan's latest blog post.

The ATSB’s Chief Commissioner, Martin Dolan, has just published his latest blog post.

In his post, Martin talks about the ATSB’s expanded role as Australia’s independent national rail safety investigator and the contribution the ATSB will make to prevent future accidents and improve rail safety.

View the Chief Commissioner’s blog at www.atsb.gov.au/infocus

• Pilots are reminded to be diligent in the performance of checklist items during all stages of flight as they are there to capture errors made before and during flight. 
• Checklists are the most readily available way to manage risks of errors and omissions.

The ATSB is urging pilots to be diligent in the performance of checklist items during all stages of flight. This reminder follows an incident where a Piper Seneca experienced fuel starvation while cruising at 9,000 ft above sea level. 

On 31 August 2012, the aircraft departed Hobart Airport for Bankstown on a private flight. At about 19 km south of Nowra, the pilot (who was the only person on board) heard a bang and the left engine stopped with the right engine stopping shortly after. The pilot immediately feathered the propellers, declared a PAN and started looking for a suitable area to land. He proceeded through the memory items on the emergency checklist. While performing the emergency checklist, the pilot discovered that the right fuel selector was in the cross-feed position and the left fuel tank had run out of fuel. He repositioned the fuel selectors and restarted both engines.

At the time of the engine restart, the aircraft had descended to 4,000 ft. The pilot advised air traffic control that both engines were now running and that he would continue to Bankstown as planned.

On landing at Bankstown, the aircraft had a significant lateral imbalance, as the left wing tank was empty and the right wing tank was almost full. As a result, the aircraft departed the runway after landing. The pilot regained control and the aircraft taxied to the parking area without further incident. The aircraft was not damaged, and the pilot was not injured.

The pilot had been accustomed to being assisted on flights by his wife, who would hold the checklist and read out the items. On this flight, however, she was not with him. Checklists are the most readily available means of risk management against errors and omissions.

Read the final report: Fuel starvation involving Piper Seneca, VH-BTW, 19 km south of Nowra Airport, New South Wales, on 31 August 2012

Carburettor icing can have serious safety implications for aircraft. This was shown most recently in an accident near Miranda Downs in Queensland.

Carburettor icing can have serious safety implications for aircraft. This was shown most recently in an accident near Miranda Downs in Queensland. On 6 July 2012, a Robinson R22 Beta was conducting mustering operations when the right skid struck a tree and collided with terrain.

The operator’s investigation into the accident—which examined GPS and Bureau of Meteorology data— found that the combination of temperature and dew point indicated a moderate carburettor icing risk at cruise power and a serious icing risk at descent power.

Pilots are reminded to maintain awareness of the weather conditions that are conducive to carburettor ice formation and closely monitor their aircraft performance during times when the risk exists.

Carburettor ice can occur in temperatures as high as 32° C with high humidity. 

The investigation report AO-2012-091 provides important advice about carburettor icing. You can find this and other investigations in the ATSB’s Aviation Short Investigation Bulletin issue 13. The bulletin highlights valuable safety lessons for pilots, operators and safety managers.

More information:

The following publications provide useful information on carburettor icing and avoidance:

• Robinson Safety Notice SN-25 – 
  Carburettor Ice (95.47 KB)
• Robinson Safety Notice SN-31 – 
  Governor Can Mask Carb Ice (421.32 KB)
• Ice Advice, in Flight Safety Australia, March-April 2006, pages 26-33
• Ice Blocked, in Flight Safety Australia, November-December 2004, pages 31-33
• The ATSB educational fact sheet titled Melting Moments: Understanding Carburettor Icing

The Civil Aviation Safety Authority (CASA) Carburettor icing probability chart(Opens in a new tab/window) can be downloaded from the web or purchased from the CASA Shop

The Robinson Safety Notice SN-38 – 

The following ATSB investigation reports provide further reading on carburettor icing:

• ATSB Report AO-2010-107
• ATSB Report AO-2009-031

Systemic safety issues in Queensland coastal pilotage operations have been identified in an Australian Transport Safety Bureau (ATSB) investigation report.

Coastal pilots form a key defence against a serious shipping incident in parts of the Great Barrier Reef and Torres Strait as part of a suite of broader protective measures already in place.

The ATSB began an investigation into coastal pilotage operations in December 2010 following the release of its report into the grounding of the piloted tanker Atlantic Blue in the Torres Strait and a request from the Australian Maritime Safety Authority (AMSA)—the coastal pilotage safety regulator. That report identified safety issues affecting coastal pilotage which indicated that other systemic issues may also exist that would benefit from the ATSB further investigating.

The ATSB’s safety issue investigation found that under the coastal pilotage regulations, no organisation, including the pilotage provider companies, has been made clearly responsible and held accountable for managing the safety risks associated with pilotage operations. This has meant that responsibility for managing the most safety critical aspects of pilotage has rested with individual pilot contractors instead of an organisation that systematically manages safety risk.

The investigation also identified systemic safety issues surrounding pilot training, fatigue management, incident reporting, competency assessment and use of coastal vessel traffic services.

AMSA has already taken and proposed safety action to address the issues identified and is working with pilots, pilotage providers and industry to make further improvements to shipping safety in the region. Significant AMSA action includes the publishing of standard passage plans for pilotage, and requiring pilotage providers to develop standard operating procedures for pilotage tasks undertaken by their contractor pilots. On 1 July 2012, AMSA also began a review of its coastal pilotage regulations.                                          

The ATSB welcomes AMSA’s response but considers further action is necessary to fully address the safety issues. In particular, the ATSB is recommending that AMSA ensures that the coastal pilotage regulations specifically assign responsibility for the safe management of pilotage operations to the pilotage providers or another organisation.

The ATSB has also issued recommendations to the three coastal pilotage providers to take safety action in relation to fatigue management and incident reporting to facilitate action by AMSA.

Following the allowed 90-day period after the issue of its recommendations, the ATSB will reassess the safety risk based on the action taken and proposed by AMSA, and the pilotage providers to address the issues.

Read the final report: Safety issue investigation into Queensland Coastal Pilotage

Three incidents at Gladstone Airport have important messages for regional aviators. The incidents, captured on CCTV footage, show three high-capacity passenger aircraft taking off at night without activating the runway lighting.

Gladstone is a non-towered, uncontrolled airport operating on a common traffic advisory frequency. The runway lighting was controlled by a pilot active lighting system that was combined with an aerodrome frequency response unity. Once activated, the lighting remains on for 30 minutes from the time of activation or reactivation. In two cases investigated, the lighting deactivated between boarding and departure. In the other the lighting was not activated at all.  

All flight crew interviewed advised that, during the taxi and take-off roll, they did not notice anything unusual or problematic with the airport lighting or environmental conditions at the airport. In addition, they reported that they had no difficulties maintaining directional control during the take-off. Until the ATSB contacted them, the crews had not been aware that the lights had de-activated in between boarding the aircraft and the aircraft taking off.

These incidents highlight the potential hazards associated with change blindness, inattention blindness and expectation bias.

Change blindness occurs when a person does not notice that something is different about the visual environment relative to before the Potential Hazard change. Research has shown that in some cases, quite dramatic changes are not detected, particularly if changes occur when the observer is not looking at the relevant part of the visual environment at the time. In this instance the crews did not notice the difference between the airport lighting when they were boarding versus when they taxied out for departure.

Inattention blindness occurs when a person does not notice an object that is visible, but unexpected, because their attention is engaged on another task. In this instance the absence of lighting was noticeable, if looked for, and the crews probably had an assumption or expectation that the lighting was on.

In simple terms, expectation bias is ‘seeing’ what you expect to see even when it is not there—in this case, runway lighting being on.

Read the final report: Take-offs without runway lighting - VH-FVL (ATR-72), VH-FVU (ATR-72), VH-QOK (DHC-8)

You can find this and other investigations in the ATSB’s Aviation Short Investigation Bulletin. The bulletin highlights valuable safety lessons for pilots, operators and safety managers.

Operators of BAC 167 Strikemaster aircraft are being urged to check the safety of their aircraft following a Coronial inquest into a fatal Strikemaster accident.

On 5 October 2006, a BAC 167 Strikemaster aircraft broke up in flight and crashed into the Turon State Forest (near Bathurst, NSW) during an adventure flight. The pilot and passenger died in the accident.

Earlier this year, the Office of the NSW State Coroner began a Coronial Inquest into the accident.  During evidence at the Inquest, details of the calculation of Fatigue Index (FI) penalties applicable to Strikemaster aircraft was provided.

As a result of this evidence, CASA recently issued an Airworthiness Bulletin (AWB 02-041 Issue 2). The bulletin recommends registered operators and maintenance organisations review the FI records for BAC Strikemaster 167 aircraft and determine if a FI penalty should be applied.

The Inquest is continuing.

The Airworthiness Bulletin(Opens in a new tab/window) is available on CASA's website.

The ATSB investigation report (200605843) into this accident can be found on the ATSB website.