The pilot in command was undergoing a check flight with a licensed pilot in the right hand seat acting as check pilot.

Both pilots stated that on downwind a landing gear down indication was noted. The gear down indication was again checked final. The aircraft landed normally on the mainwheels but as the nose was lowered the nose gear collapsed and the propeller and nose struck the runway.

After landing, the pilot stated that the landing gear lever was in the "down" position. The landing gear operation was checked by a maintenance engineer and found to be normal.

The reason for the gear collapse was not determined.

About 20 minutes into the flight the pilot detected a change in engine noise. Scanning the engine instruments, he noticed the manifold pressure and fuel flow indications had decreased and were continuing to fall slowly.

Application of full throttle and rich mixture had no effect, but when he changed fuel tanks, switched the emergency boost pump on, and check each magneto individually, the power decreased further. Leaning the mixture tended to increase power momentarily.

Retarding the throttle a small amount resulted in a substantial loss of power with the aircraft unable to maintain normal flight. After briefing the passengers and transmitting a "Mayday" call, the pilot carried out a forced landing into lightly timbered country. The aircraft was substantially damaged, but the pilot and passengers escaped uninjured.

Subsequent examination revealed that the throttle/mixture control cable support bracket had fractured, causing a loss of throttle movement between the cockpit control and the fuel control unit at the engine. The fracture was the result of a fatigue crack in the support bracket. The crack had propagated over a period of time.

The tug aircraft, VH-WGC, was holding to the left of the threshold of the strip while a knot was being cleared in the tow rope attached to a glider to be launched.

Another glider, VH-IKU, was engaged on solo circuits and was to land to the right of VH-WGC. VH-IKU bounced on landing and began to swing to the left. In an attempt to correct the swing, the pilot mistakenly applied left rudder, and the glider struck the tail of the tug. The occupants of all aircraft escaped without injury.

Safety summary

What happened

On 11 June 2015, four Rhomberg Rail Australia track machines were travelling in convoy on the Australian Rail Track Corporation Hunter Valley (NSW) corridor between Maitland and Scone. The vehicles travelled coupled in two pairs as train 5M71N.

To allow a passenger train to pass en route, 5M71N was required to leave the Down main line and enter a siding at Singleton. After arriving at Singleton, the Traffic Officer travelling with 5M71N accessed a local control panel to operate a crossover from the down main line to the siding. The points at each end of the crossover appeared to operate but the indication light on the panel did not illuminate to confirm detection of the points in the required position. The Traffic Officer visually inspected the position of the points from a location adjacent the control panel.

As the points appeared to be set, the Traffic Officer concluded there was likely a fault with the indicator light. The Traffic Officer contacted the Australian Rail Track Corporation Network Control Officer for authority to enter the siding but did not mention that the indication lamp had not illuminated.

At about 0823, as the convoy entered the turnout from the main line, the operator on the lead vehicle saw that the swing-nose crossing in the turnout ahead was not in the correct position. The vehicles were travelling at about 15 km/h and the operator was unable to stop before passing over the crossing - derailing the lead vehicle, M395, and the leading axle of the trailing vehicle, M2256. There were no injuries, but the derailed vehicles obstructed the Down main line.

What the ATSB found

The ATSB found that the machine driving the swing-nose crossing on the Down main line turnout had not operated in conjunction with the companion point machines of the crossover. An internal electrical fault likely resulted in the machine failing to move to the required position. As designed, the E Frame local control panel reverse lamp did not illuminate to confirm the correct operation of the crossover.

The Traffic Officer did not notice the swing-nose point machine failed to operate. As the route appeared to be set correctly, the Traffic Officer concluded that the reverse indication lamp on the E Frame local control panel was faulty. The Traffic Officer did not report the lack of a reverse indication to the NCO and a systematic examination of the crossover was not undertaken before advancing the track machines.

The ATSB also found the operating method and indications displayed were unique for both the E Frame field equipment and the control centre. The Australian Rail Track Corporation procedures did not effectively explain the current operational arrangements for this equipment.

What's been done as a result

The Australian Rail Track Corporation (ARTC) issued an Incident Notice, instructing the Network Control Officers not to authorise passing signals at stop for the turnout route if the REV indication or panel light did not display. Additionally, new Network Information Books and revised guidance documentation for the operation of the E Frame panel were developed.

Rhomberg Rail Australia implemented actions to ensure track personnel are familiar with the operation of the E Frame and the implementation of the ARTC Network Rules.

Safety message

Rail safety workers must fully implement and adhere to the applicable network operational procedures in response to any abnormality observed when operating rail infrastructure. Rail infrastructure managers must ensure that operating procedures and instructions for track equipment are maintained and fully representative of the equipment installed.

Appendices

Appendix A – ARTC Incident Advice

 

Context

Location

Singleton is located at the 238.9 km mark^[2] on the Australian Rail Track Corporation (ARTC) Hunter Valley corridor in New South Wales. It is about 46.4 track-km from Maitland and 75.8 track-km from Scone. The Down siding at Singleton was accessible via a crossover at either end of the Singleton yard. A Lever Ground Frame and Control panel, designated ‘B Frame’ and ‘E Frame’ respectively, enabled a qualified worker to locally operate the adjacent crossover after obtaining a release from the NCO.

Train 5M71N

The convoy of track vehicles were transferring from Maitland to Scone under ARTC timetable No 046-2015 and designated as train movement 5M71N.

The convoy comprised four track maintenance vehicles coupled in pairs. The first pair consisted of a Plasser SSP–303 Ballast Regulator (M521) and a Plasser Unimat 08-475/4s Tamper (M946). The second pair consisted of a Plasser 09-32 Tamper (M2256) and a Plasser SSP–100 Ballast Regulator (M395). The first pair of vehicles led the convoy when it departed Maitland and up to the limit of its current authority at Singleton. After the convoy stopped, it was required to reverse the direction of travel in preparation to access the Down siding via the E Frame crossover. The second pair then became the lead vehicles of 5M71N.

Traffic Officer

The RRA Traffic Officer travelling in the second pair of vehicles was the qualified worker in charge of movement 5M71N. The RRA Traffic Officer performed the role of Protection Officer, responsible for the co-ordination of all safeworking arrangements for 5M71N with the NCO.

Safeworking arrangements for Train 5M71N

The ARTC Network Rules required that, in track-circuited territory^[3], the vehicles of 5M71N were block worked^[4] or authorised for travel under a Track Occupation Authority. This was because the track vehicles were not authorised in the ARTC Train Operating Conditions manual as operating track–circuits reliably. In this case, the NCO managed the progress of 5M71N toward Singleton through the issue of a Track Occupation Authority (TOA) for the required section of track, rather than implementing block working or the remote operation of lineside signals as would be the case for authorised rail traffic such as a passenger train.

The NCO issued a TOA up to signal 148.9 in Singleton, advising the Traffic Officer to enter the Down siding via the ‘E’ Frame. This was because the ‘B’ Frame, which was the first access point to the siding in the direction of travel, was temporarily booked out of use under an Infrastructure Booking Authority (IBA). An IBA is used to tell Train Controllers and Signallers [NCOs] that infrastructure equipment is temporarily or permanently removed from service (booked out of use) or installed/returned to service (booked into use).

E Frame crossover

The crossover from the Down main to the Down siding comprised motorised point machines at each end and a motorised swing-nose at the “V” crossing of the turnout on the Down main line. The “V” crossing of the turnout on the Down siding was of a non-movable compound type (Figure 5).

Figure 5: Singleton yard E Frame Crossover

The E Frame Crossover showing 2EA and 2EC points at each end of the crossover and the 2EB swing-nose crossing at the junction of the Down main line and crossover rail. The points illustrated are set for the normal (straight through direction). The vehicle pair (M395 and M2256) derailed at the 2EB swing-nose crossing that did not operate to reverse. Source: Australian Rail Track Corporation, annotations by ATSB

E Frame control panel operation

The operation of E Frame was unique due to its configuration as a ‘ground frame operated by a local control panel’ and the separation of signal and point controls between the Broadmeadow control centre and the local control panel. That is, only local control from E Frame was available for the crossover, and only remote control from the control centre was available for the signal.

Operation of the E Frame required a release from Broadmeadow control centre for the qualified worker to operate a push button to motor the point machines to the reverse position. A light on the control panel (Figure 9) would illuminate to indicate the crossover had operated correctly. The NCO could then give authority to access the Down siding, through the clearance of a fixed signal or other form of authority as required.

A typical local panel configuration provides indicator lights to show that the points are responding to the operation of the point-setting controls and, once operated, are set in the required position. The point indicator lights will also typically display a ‘flashing point transit indicator’ to show that the relevant points are either not in position, the locking not engaged, or the points are in the process of changing position.

The design of the indication lights on the E Frame control panel in this instance, did not include the functionality to display a flashing indication to the operator as the points transitioned. Following selection of the required point-setting control, the corresponding indicator light would extinguish and only illuminate following detection of the points in the correct position. Of note, the panel operation procedure did not document this behaviour.

In this instance, after the Traffic Officer commanded the points to move for access to the Down siding, the reverse light did not illuminate to indicate all motorised machines were in the correct position for safe access the siding. Post-incident, ARTC engineering staff inspected the E Frame and points machines; finding that the E Frame control panel operated correctly but the swing-nose machine did not operate. A motor start capacitor terminal had disconnected in the machine due to a broken mounting plate. While this would have prevented the motor from operating, it could not be conclusively determined if this damage was pre-existing or a consequence of the derailment.

Broadmeadow Phoenix control system

The Phoenix control system at Broadmeadow provided the control and indication functions for the associated signalling infrastructure. The indications provided to the NCO would change dependent on the configuration of the associated field equipment. The screens typically displayed a point (track) indication corresponding to the detected position. The indication would also typically flash to show that the relevant points were not detected in position, the locking not engaged, or the points were changing position.

The segregation of control between Broadmeadow control centre and the local E Frame control panel meant the indications for E Frame points displayed on the Broadmeadow control screens were also unique.

Normally, the track indication for the E Frame points showed them as set for straight-through on the Down main line (Figure 6) and the text ‘PT IND’ was displayed. This indicated to the NCO that the points were set and detected in the normal position.

Figure 6: Phoenix screen extract showing E Frame points detected normal

The E Frame indication (circled) seen by the NCO when the E Frame points were in the normal position. The indications of the tracks over the points show as straight through. This corresponds to the position of the E Frame points. Source: Australian Rail Track Corporation

When the NCO provides a ‘release’ for the operation of the E Frame by a qualified worker at Singleton, the track indication for the E Frame points changes to show them released for movement to access the Down siding, and the text ‘REL E’ is displayed (Figure 7). This indicates to the NCO that the points release has been set. Although the Phoenix graphic for the E Frame points was now orientated to represent the points in the reverse position, a qualified worker (at Singleton) may be yet to actually move the points to the reverse position (via the local E Frame panel). That is, when the points release is set, the Phoenix track display graphic at the control centre shows the E Frame crossover in the reverse orientation – regardless of their actual position at Singleton.

Figure 7: Phoenix screen extract showing E Frame released

The ‘REL E’ indication displayed to the NCO after setting the control that allows the qualified worker at Singleton to operate the E Frame. The indications of the tracks over the points show as set for the crossover but the E Frame points may still be set as straight through. Source: Australian Rail Track Corporation

After receiving the release, the qualified worker at Singleton could then operate the points reverse pushbutton. The E Frame points should then travel to the reverse position. Once detection for the reverse position was correct, the text ‘PT IND’ was replaced by ‘REV’ on the Phoenix display (Figure 8). This indicated to the NCO that the points had operated correctly and an authority could be issued for vehicle movement to the Down siding.

Figure 8: Phoenix screen extract showing E Frame points detected reverse

The REV indication (circled) seen by the NCO after detection of E Frame points in reverse following the operation by the qualified worker at Singleton. The E Frame points are set for the crossover. Source: Australian Rail Track Corporation

The indications provided to display to the NCO the orientation of the E Frame points are not consistent with those typically displayed for other points within the Phoenix system. This variability in the representation of point positions may result in the NCO misinterpreting the information presented; increasing the risk of a verbal movement authority being provided before it was safe to do so.

The ARTC published, post-incident, an Incident Advice Notice (Appendix A – ARTC Incident Advice) to the NCO’s at Broadmeadow – clarifying the ‘REV’ indication on the Phoenix display for the Singleton E Frame, and procedures for authorising of a movement to pass a signal at stop.

Authorising rail traffic to pass an absolute signal

The method of E Frame operation at Singleton required the qualified worker onsite to coordinate with the NCO to operate the points, before receiving authority from the NCO to pass a signal. If the NCO used a fixed signal to communicate a proceed authority, the signal interlocking would require detection of the correct points position before allowing the signal to clear. If the NCO provided authority without the use of a fixed signal, the NCO was reliant on visually checking the correct indications displayed on the Broadmeadow control panel (Phoenix display) and the qualified worker confirming the correct operation of the points – before the authority could be issued.

Within yard limits, the ARTC Network Rules^[5] stipulate the conditions that track vehicles must be worked. These conditions allow travel on the authority of fixed signals or on the Signaller’s (NCO’s) verbal authority. In this case, fixed signal 78 was not available for use as it was booked out of use due to the extended time following the previous rail movement^[6] The NCO therefore gave the RRA Traffic Officer a ‘Signallers’ verbal authority to pass 78 signal.

When providing an authority to pass a signal at stop, drivers or track vehicle operators and signallers use a specific form of words. This is to ensure that drivers and track vehicle operators clearly receive and understand the authority to pass an absolute signal at stop.^[7] A review of the voice logs from the Broadmeadow network control centre found that the NCO and RRA Traffic Officer did not implement the required communication protocols during the request or provision of the authority to pass 78 signal. While this instance of compliance with the communication protocol was deficient, it was not a contributing factor in the subsequent derailment of the track vehicles.

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2. All track distances in this report are referenced from the Sydney Central Station.
3. The portions of line where electrical track-circuits are used for the Rail Vehicle Detection system of Safeworking.
4. A method of special working which ensures sole occupancy by manually maintaining the block behind a rail traffic movement.
5. Australian Rail Track Corporation Network Rules - ANWT 316 Track Vehicles, May 2007 Issue 2 Rev 2
6. Australian Rail Track Corporation Network Rules – ANGE 220 Unreliable track-circuit operation, November 2008 Issue 2 Rev 0 - Network Control Officers must treat the operation of track-circuits that have not been travelled over by rail traffic for 72 hours or more as unreliable.
7. Australian Rail Track Corporation Network Rules – ANPR 746 Authorising rail traffic to pass an absolute signal at STOP.

Findings

From the evidence available, the following findings are made with respect to the derailment of track vehicles M395 and M2256 at the E Frame swing-nose crossover in Singleton on 11 June 2015. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Safety issues, or system problems, are highlighted in bold to emphasise their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.

Contributing factors

• A swing-nose point machine in the Down main line turnout did not operate to reverse in conjunction with companion point machines of the crossover.
• The point indication functionality on the E Frame local panel was unique, in that it did not include a ‘flashing point transit indicator’ in the absence of reverse detection.
• The Traffic Officer perceived the indicator to be faulty and concluded that all points in the E Frame crossover were set correctly.
• The Traffic Officer did not report the (perceived) faulty point indication to the Network Control Officer.
• The Traffic Officer did not implement existing network procedures for responding to the (perceived) faulty point indication.
• The Network Control Officer did not observe the available Phoenix display information, regarding the condition of the E Frame crossover prior to authorising the passing signal 78 at stop.

Other factors that increased risk

• The ARTC Network Control centre procedures did not address the unique operation of the Singleton E Frame equipment to ensure correct and consistent interpretation of the indications provided on the Phoenix display. [Safety issue]
• The ARTC Local Appendix Unit North – Volume 3 did not reflect current equipment installation arrangements for E Frame at Singleton. [Safety issue]

Other findings

• Local operating instructions and panel for E Frame contained hand-written amendments.
• The Network Control Officer and Traffic Officer did not follow the required Network communication protocols when authorising 5M71N to pass 78 signal at stop.

Safety analysis

E Frame local panel operational procedures

An instruction sheet describing the method of operation for the panel was located within the E Frame’s local control cabinet. This instruction and the local control panel faceplate however, contained various hand written corrections and supplementary advisory instructions for the qualified worker operating the panel (Figure 9).

Figure 9: E Frame local panel faceplate and instruction sheet

The switches and lamps on the E Frame panel used to set and indicate the position of the E Frame points. Each switch and lamp had a permanent label to identify its function. Users had added additional handwritten instructions to clarify the operation and meaning of the various labels and contents of the instruction sheet. Source: Australian Rail Track Corporation, annotations by ATSB

None of the instructions referred to the unique arrangement for the Points Normal or Points Reverse lamps displaying only a steady indication when the points were set in the required position. The absence of a flashing indication during the transition of the points to the reverse position likely contributed to the Traffic Officers perception that the lack of the Points Reverse indication was due to a lamp fault.

In addition to the sheet affixed to the E Frame, instructions for the operation of rail infrastructure are contained in the ARTC NSW Network Rules & Procedures and the ARTC Local Appendix Units. Neither of these documents contained information that reflected the particular method of operation of the Singleton E Frame. Instruction in the ARTC Local Appendix Units applicable to Singleton referenced a different (redundant) arrangement for the operation of E Frame.

It was evident that, at the time of the derailment, the ARTC had not updated all relevant operating procedures/local appendix units to reflect the unique arrangements for the E Frame local control panel. This departure of the equipment arrangements and operational behaviours from documented procedures, may result in a qualified worker misinterpreting the information presented by the indicator panel lights.

Responding to faulty points

The ARTC Network Rules^[8] require a qualified worker to respond to an anomaly in the operation of point machines by reporting the occurrence to the Signaller (NCO). The NCO and qualified worker then coordinate to undertake a systematic inspection of the points to diagnose the fault. If the fault cannot be readily rectified the qualified worker may be instructed to operate the points manually and apply additional mechanical locks to prevent unintended operation.

In this instance, the RRA Traffic Officer discussed the E Frame indication anomaly with co-workers, but did not report the issue to the NCO. The RRA Traffic Officer undertook a brief visual inspection of the points, but did not continue to apply the required procedure for responding to faulty points. Based on the sequence of events in this occurrence, the correct implementation of the ARTC Network Rules may have prevented the subsequent derailment of 5M71N.

Following the derailment, Rhomberg Rail Australia developed the following safety actions to ensure their track personnel correctly implement the ARTC Network Rules:

• Conduct a full review of the Network Rules with all employees
• Develop flow charts to identify the process flow for critical operations of points/transfers.
• Complete a ‘standard setting’ workshop with all Resurfacing employees
• Update Network Rule folders on all the machines
• Create a network rule register
• Recertify employees involved in the incident in their respective highest level of safe working
• Management observation of Network Rule compliance.

Passing signals at stop

The ARTC Network Rules^[9] require a Signaller (NCO) to get available information about the condition of the block ahead, using:

• The track indicator diagram
• Records of previous rail traffic movements
• Work on track authority records
• Reports about the location of the last rail traffic to enter the block, or
• The signaller at the other end of the section

In this instance, relevant information was obtainable from indications displayed on the Phoenix screen and the RRA Traffic Officer operating the E Frame at Singleton. Using this information the Network Rule required the NCO, before providing authority to pass a signal at stop, to make sure that the:

• Points are set correctly for the route, and
• Points that are facing points, or become facing points, are secure.

The NCO did not identify the points were correctly set using the indications displayed on the Phoenix screen or confirm with the RRA Traffic Officer that conditions of the track ahead were correct and the points in the crossover secured. Again, the correct implementation of ARTC Network Rules may have prevented the subsequent derailment of 5M71N.

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8. Australian Rail Track Corporation Network Rules – ANPR 740 Responding to faulty points
9. Australian Rail Track Corporation Network Rules – ANSG 608 Passing signals at STOP

Safety issues and actions

The safety issues identified during this investigation are listed in the Findings and Safety issues and actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.

All of the directly involved parties were provided with a draft report and invited to provide submissions. As part of that process, each organisation was asked to communicate what safety actions, if any, they had carried out or were planning to carry out in relation to each safety issue relevant to their organisation.

The initial public version of these safety issues and actions are repeated separately on the ATSB website to facilitate monitoring by interested parties. Where relevant the safety issues and actions will be updated on the ATSB website as information comes to hand.

Unique indications for E Frame on Network control system screens

The ARTC Network Control centre procedures did not address the unique operation of the Singleton E Frame equipment to ensure correct and consistent interpretation of the indications provided on the Phoenix display.

Rail Safety Issue No: RO-2015-010-SI-01

Local Appendix Unit – North V3

The ARTC Local Appendix Unit North – Volume 3 did not reflect current equipment installation arrangements for E Frame at Singleton.

Rail Safety Issue No: RO-2015-010-SI-02

Sources and submissions

Sources of information

The sources of information during the investigation included the:

• Australian Rail Track Corporation
• Rhomberg Rail Australia

References

Australian Rail Track Corporation Network Rules & Procedures – NSW

Australian Rail Track Corporation Local Appendices North Volume 3 Maitland to Muswellbrook 10 August 04 Version 1.0

RISSB Glossary of Railway Terminology – Guideline Version 1, December 2010

Rhomberg Rail Australia Incident Investigation report ARTC – Singleton Yard [Draft]

Submissions

Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety Investigation Act 2003 (the Act), the Australian Transport Safety Bureau (ATSB) may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to make submissions to the ATSB about the draft report.

A draft of this report was provided to the Australian Rail Track Corporation, Rhomberg Rail Australia, the Office of the National Rail Safety Regulator and the relevant crewmembers of 5M71N.

Submissions were received from Australian Rail Track Corporation, Rhomberg Rail Australia, the Office of the National Rail Safety Regulator and one crewmember of 5M71N. The submissions were reviewed and where considered appropriate, the text of the report was amended accordingly.

The occurrence

At about 0648^[1] on 11 June 2015, a convoy of four Rhomberg Rail Australia (RRA) track vehicles departed Maitland travelling toward Scone in NSW (Figure 1). The vehicles travelled coupled in pairs as train movement 5M71N. As 5M71N approached Whittingham, the RRA Traffic Officer travelling aboard contacted the ARTC Network Control Officer (NCO) at the Broadmeadow control centre to obtain the next authority to proceed.

Figure 1: Locations Maitland to Scone

Map showing the rail line taken by 5M71N from Maitland toward Scone. Source: Geoscience Australia annotations by ATSB

The NCO advised that 5M71N was required to leave the Down main line and enter the Down siding at Singleton to allow a passenger train to pass. The NCO then issued a verbal authority (Track Occupancy Authority) for 5M71N to travel from Whittingham to signal 148.9 at Singleton. The NCO also instructed the RRA Traffic Officer to check that all points in the track were set correctly before proceeding over them.

The NCO told the RRA Traffic Officer to enter the siding at Singleton via the ‘E Frame’ at the northern end of the yard, because the ‘B Frame’ was out of service. The NCO remotely operated the ‘release’ for the E Frame control panel to allow the local operation of the crossover by the RRA Traffic Officer following arrival at signal 148.9.

The E Frame control panel operated motorised point machines in the crossover for access to the Down siding. To enable the RRA Traffic Officer to operate the point machines, all vehicles in 5M71N had to pass signal 78. (Figure 2)

Figure 2: Singleton yard simplified track and signal layout

Simplified track layout of Singleton yard showing path of 5M71N. The two pairs of vehicles entered from Whittingham and stopped between signals 78 and 148.9. Once the points in the E Frame crossover were set, the vehicles reversed direction of travel to enter the Down siding via the crossover. Source: Graham Vincent, Track and Signal, annotations by ATSB

After arriving at Singleton, all vehicles in 5M71N stopped clear of 78 signal. The RRA Traffic Officer accessed the E Frame control panel, and as the release was already set, operated the release switch and pushed the points reverse button for access to the siding.

The motorised point machines in the crossover should then move the points to the selected position and the reverse (REV) indication lamp on the panel should illuminate. When illuminated, the reverse indication lamp provides confirmation to the operator that all points had operated correctly.

On this occasion, one of the motorised point machines in the crossover did not move to the reverse position in conjunction with the other machines on the crossover. As designed, the reverse indication lamp on the E Frame panel did not illuminate, indicating a failure had occurred and the points may be in an unsafe condition.

Figure 3: Location E Frame control panel

View looking North along the Down Siding toward signal 78 showing position of the E Frame control panel relative to the E Frame crossover. Source: Australian Rail Track Corporation, annotations by ATSB

Responding to the absence of the REV indication, the RRA Traffic Officer visually inspected the orientation of the points from a location adjacent the E Frame control panel (Figure 3).

Perceiving the alignment was correct, the RRA Traffic Officer discussed the indication lamp anomaly with a co-worker travelling with 5M71N. As the points appeared to have operated, they concluded there was likely a fault with the indication lamp and the crossover was correctly set to proceed.

The RRA Traffic Officer did not inspect the lie of each point on the crossover to confirm whether the corresponding machine had operated to the required position and the locking mechanism had engaged correctly.

The RRA Traffic Officer then contacted the NCO for authority to pass signal 78 at stop and enter the siding, but did not mention that the reverse indication lamp had not illuminated. The NCO, unaware of the points failure, provided a ‘signalman’ authority to pass signal 78, which the Traffic Officer subsequently relayed to the operator of the lead vehicle of 5M71N.

At about 0823, as the lead vehicle traversed the turnout from the Down main line the operator saw the swing-nose crossing ahead was not in the correct position. The vehicle was travelling at about 15 km/h but the operator was unable to stop before passing over the swing-nose crossing.

The leading vehicle (M395) and the leading axle of the trailing vehicle (M2256) derailed as they passed over the swing-nose crossing that had failed to operate in conjunction with the other machines in the crossover (Figure 4). The lurching of the vehicles following the derailment impeded the ability of M395’s driver to operate the brake or other controls until the vehicles had stopped. The derailment obstructed the Down main line and resulted in minor damage to the track vehicles. There were no injuries.

Figure 4: Derailed track vehicles M2256 and M395

View from the Down Siding of the derailed vehicles on the crossover. The vehicles M2256 and M395 (in foreground) were the first to pass signal 78 for entry into the Down Siding. The vehicles derailed at the swing-nose crossing that is located at the junction of the E Frame Crossover and Down Main Line rails. Source: Australian Rail Track Corporation, annotations by ATSB

Post-incident, ARTC representatives inspected the crossover; finding that it was likely that the motorised machine that was part of the swing-nose crossing in the turnout on the Down main line had failed to properly operate – rendering the points unsafe. At about 1900 that day, the recovery of the derailed track vehicles and repair to the E Frame points was completed.

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1. The 24 hour clock is used in this report to describe the local time of day, Eastern Standard Time (EST).

Purpose of safety investigations & publishing information

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through: identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. Terminology An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information  Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2016 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

What happened

At about 1335 Eastern Standard Time (EST) on 15 July 2015, the pilot of an Extra 300L aircraft (Extra) VHKCF, was returning to Bankstown Airport, New South Wales, after completing a local, private flight. The pilot, the sole person on board, reported inbound to Bankstown Tower at the TWO RN reporting point (Figure 1). At this point, the Extra was maintaining 1,500 ft above mean sea level. Air Traffic Control (ATC) cleared the aircraft to join the crosswind leg of runway 29R and to maintain 1,500 ft.

Shortly after the pilot of the Extra had called inbound, the pilot of a Robinson 44 helicopter (R44), VH-OLG also called Bankstown Tower with inbound details, from overhead the Olympic Stadium, about 6 NM northeast of Bankstown Airport. The R44, with the pilot and three passengers on board, had just completed a scenic charter flight over the Sydney CBD. ATC requested the pilot to report again at Choppers North (Figure 1). The pilot descended to the required 700 ft and reported at Choppers North.

Figure 1: Helicopter inbound procedures diagram for Bankstown Airport.Note the Choppers North inbound reporting point as used by VH-OLG (purple arrow). On this occasion, VH-OLG was inbound from the northeast. TWO RN, the inbound reporting point for VH-KCF is also marked (yellow circle)

From Choppers North, ATC instructed the R44 pilot to continue the approach and report on base leg. The pilot complied with this instruction, and reported on an ‘early base’. ATC then cleared the R44 for a November One (N1) arrival (Figure 2).

N1 arrival

An N1 arrival could only be conducted by appropriately trained and qualified pilots (such as the pilot of the R44). The arrival allowed a visual approach from the helicopter circuit altitude of 700 ft via an oblique approach to taxiway N1 (Figure 2). In an N1 arrival, the Tower were unable to see a helicopter during the latter part of the approach. So the pilot was required to advise the Tower when they had landed.

Figure 2: Bankstown Airport showing the N1 taxiway used as a landing site for a November One arrival (green)

Source: Airservices Australia – ERSA extract for Sydney / Bankstown

Meanwhile, as the Extra tracked to join crosswind for 29R, ATC alerted the pilot about a conflicting DR-107 One Design aircraft. The DR-107 had been cleared for take-off from runway 29C, and to initially maintain runway direction on climb to 1,500 ft.

The pilot of the Extra reported sighting the DR-107. The Extra pilot then requested a clearance to conduct a touch and go circuit on runway 29R. Once in receipt of this clearance, the pilot left 1,500 ft on descent, making a continuous turn onto base and then final approach. To enhance forward visibility the pilot then sideslipped the aircraft toward the landing threshold (Figure 3).

During the descent and sideslip of the Extra, the pilot of the R44 continued their descent at about 100-150 fpm toward N1. While descending through about 350-300 ft, the passengers and pilot on the R44 saw the underside of the Extra pass from right to left in front of the helicopter. They estimated it was within 100 ft of the R44’s altitude and about 70-100 m in front of them (Figure 5).

ATC again advised the pilot of the R44 to report after landing. The pilot replied to ATC that the Extra had just passed very close by them. The pilot of the Extra responded with a comment that they had seen the traffic.

The R44 pilot continued with the landing onto N1, reporting to tower after landing, and the pilot of the Extra, who was still not aware of the helicopter, continued with the touch and go prior to being cleared to land on runway 29C at the completion of another circuit.

Figure 3: An example of an Extra 300 L aircraft showing the seating position of the pilot. This gives an indication of the reduced visibility with the aircraft nose slightly raised, which occurs when the aircraft is at a slower speed

Source: Jim Groom

Figure 5: Radar plot showing both aircraft approaching their relative landing areas

Source: Airservices Australia

Note: Tower Situational Awareness Display (TSAD) was not available for the provision of separation to the controllers in Bankstown tower. These images are included to show what was recorded.

Figure 6: Radar plot showing the R44 VH-OLG (light blue) at about 500 ft tracking toward N1 and VH-KCF (red) on a continuous descending approach to runway 29R

Source: Airservices Australia

Note: Tower Situational Awareness Display (TSAD) was not available for the provision of separation to the controllers in Bankstown tower. These images are included to show what was recorded.

Airservices Australia

According to the Manual of Air Traffic Services, (MATS), in Class D airspace such as Bankstown, ATC should provide a traffic information service for visual flight rules (VFR) to VFR aircraft about other known or observed air traffic which may be in proximity to the position or intended route of flight and to help the pilot avoid a collision.

As per Bankstown ERSA section 14.1 (b), the helicopter was required to remain within the fixed wing circuit during the N1 arrival, thus traffic information would not normally have been provided.

Airservices Australia advised that the tower controller on duty did not assess the traffic to be in confliction, and did not sight the incident.

They also advised that the controller complied with the requirements of the Manual of Air Traffic Services (MATS) and the Aeronautical Information Publication (AIP) in relation to traffic information.

Extra, VH-KCF - Pilot comments

The pilot of the Extra held a Commercial Pilot’s Licence for both fixed wing aircraft and helicopters. They had about 450 tailwheel aircraft hours and about 150 of these on the Extra, VHKCF.

When flying the Extra, as on this day, the pilot completed a continuous descent once cleared for a visual approach on downwind. As per normal in the Extra, the pilot side-slipped the aircraft down final approach. Side-slipping allowed the pilot better forward visibility at the slower approach speed, while also keeping the runway threshold continuously in sight.

The pilot realised in hindsight, that when the potentially conflicting traffic (VH-OLG) was passed late in the circuit, they had assumed ATC was referring to the previous traffic alert involving the DR 107. The pilot was not aware of the R44, nor that a N1 arrival could cause a conflict.

R44 helicopter, VH-OLG - Pilot comments

The pilot held a Commercial Pilot’s Licence (Helicopters) and a Grade 2 Instructor rating (Helicopter) with about 1,300 hours on helicopters. The pilot also held a private licence for fixed wing aircraft and had about 1,000 hours on this category of aircraft.

The pilot stated that Bankstown ATC manage both the fixed wing and helicopter circuits well. However, in recent times felt that there have been a few more ‘near collisions’. This may be due to the increase in helicopter movements, and overall increase in aircraft movements.

The pilot commented that they thought that the pilot of the Extra would not have been able to see the helicopter during the sideslip.

ATSB Comment

A search of the ATSB’s occurrence database for near collision incidents at Bankstown Airport between January 2013 and May 2015 did not reveal any near collisions involving helicopters.

There was one separation occurrence, (201408721), which involved the N1 approach. On that occasion, an inbound helicopter did not track as cleared to N1 and conflicted with another helicopter about to depart N1. ATC issued a safety alert to the helicopter departing N1.

The ATSB monitors trends on all occurrences recorded in its database, including near collisions. Recent trend monitoring identified that another Class D Airport, Jandakot, had a disproportionate rate of aircraft near‑collisions. Specifically, between 2013 and 2015 Jandakot Airport had a near‑collision rate that was at least three times higher than other similar metropolitan Class D airports across Australia. In response to this identified transport safety matter, the ATSB has commenced an investigation to identify the factors that increase the collision risk to aircraft operating at Jandakot Airport (see AI-2015-063 available at www.atsb.gov.au).

Safety message

This incident serves as a reminder to keep a good lookout at all times, including in Class D airspace. Pilots are responsible for maintaining separation in Class D airspace. The Civil Aviation Safety Authority pilot guide for Bankstown Airport, along with seven other Class D airports has been incorporated into the “On Track” pre-flight visualisation tool for both fixed and rotary wing pilots. This tool for VFR pilots is available on the CASA website.

A safety education publication and e-learning tutorials on Class D operations are also available on the CASA website. Note that all these publications are for safety education purposes and do not replace information in the Aeronautical Information Publication (AIP), the en-route supplement Australia (ERSA) and / or Notices to Airman (NOTAMS).

Aviation Short Investigations Bulletin - Issue 45

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through: identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. Terminology An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information  Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2015 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

 

What happened

Late in the afternoon on Sunday 19 July 2015, an amateur-built Stoddard Hamilton Glasair SH-2FT two-seat aeroplane, registered VH-HRG and operated in the Experimental category, was seen flying due north, consistent with the downwind leg of a circuit for landing at Wedderburn Airport, New South Wales.

Witnesses stated that they heard the aircraft’s engine surge twice and then silence, prior to hearing the aircraft collide with wooded terrain about 900 m north of the runway threshold. No witness reported seeing the aircraft turn onto the base leg or final approach, nor the aircraft collide with terrain.

The pilot sustained serious injuries, the passenger was fatally injured, and the aircraft was destroyed.

What the ATSB found

The ATSB found that during the turn onto final approach to land, the aeroplane’s engine ceased operating. Following the loss of power, the pilot was unable to control the aircraft’s descent to an appropriate forced landing area before colliding with the ground.

The ATSB also found that the loss of power was probably due to carburettor icing. No defects were identified that would have precluded normal operation of the aircraft or its engine prior to the accident. However, the environmental conditions at the time were conducive to serious carburettor icing at all power settings. The pilot reported using a low power setting during the downwind leg of the circuit to slow the aircraft down and did not use the carburettor heat system.

There was insufficient evidence to support other possible hypotheses for the aircraft’s loss of control, such as an aerodynamic stall as a result of aircraft handling.

Safety message

The ATSB advises pilots of aircraft fitted with a carburettor to check the forecast weather conditions affecting their operations, and consider the risk of carburettor icing prior to each flight. Pilots should be aware that carburettor icing can form over a wide range of outside air temperatures and relative humidity and understand the importance of following aircraft manufacturer guidelines regarding the use of carburettor heat. Further, they should be mindful that certain flight conditions, such as lower engine power settings, may increase the risk of ice accumulating in the engine’s carburettor.

The Civil Aviation Safety Authority’s Carburettor icing probability chart provides helpful guidance for pilots to determine carburettor icing probability before flying. The chart is available at www.casa.gov.au.

Photograph of VH-HRG

Source: NSW Sport Aircraft Club

Findings

From the evidence available, the following findings are made with respect to the loss of power and collision with terrain involving Glasair SH-2FT, registered VH-HRG, near Wedderburn Airport, New South Wales on 19 July 2015. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Contributing factors

• The meteorological conditions at the time of the accident, combined with the aircraft’s low engine power setting during the downwind and base legs of the circuit, probably resulted in carburettor ice formation.
• The lack of application of carburettor heat increased the likelihood of the formation of carburettor icing and, as a result, the engine losing power.

The occurrence

At about 1625 Eastern Standard Time^[1] on Sunday 19 July 2015, the pilot and passenger of an amateur-built Stoddard Hamilton Glasair SH-2FT two-seat aeroplane, registered VH-HRG and operated in the Experimental category, took off from runway 17^[2] at Wedderburn Airport, New South Wales. The pilot recalled a ‘shallow’ take-off due to the aircraft’s weight (two people on board plus almost full fuel) and the characteristics of the aircraft’s wooden cruise propeller.

At 1628, an unverified aircraft was observed on Airservices Australia surveillance radar for the area, consistent with the position of VH-HRG. The aircraft tracked in a south-south-westerly direction toward Wollongong. At about 1639, when near Wollongong, the aircraft turned left and commenced tracking back to the north (Figure 1).

Figure 1: Radar trace of the aircraft that appeared on Airservices Australia surveillance radar in the area of Wedderburn Airport at 1628 (at the top, with the aircraft’s radar returns shown in lilac) and the radar trace and returns (also in lilac) overlaid on Google earth (right)

Source: Airservices Australia and Google earth, modified by the ATSB

Witnesses stated that, at about 1649, the aircraft was seen flying due north, consistent with the downwind leg of a circuit in preparation for landing on runway 17 at Wedderburn Airport. The pilot recalled that the aircraft’s airspeed was higher than preferred on downwind, being greater than 100 kt. The pilot reported attempting to reduce airspeed by adjusting power and the aircraft’s attitude. However, the airspeed remained high when on late downwind. The pilot indicated that by that time, power had been reduced to the idle position. The pilot further indicated that when on downwind, the aircraft was closer to the runway than normal.

The pilot commenced a continuous turn onto base and final at an airspeed of about 90 kt and applied full flap. The pilot indicated that the power setting remained at idle until approaching the finish of the turn onto final. The pilot then attempted to apply power to arrest the aircraft’s deceleration. However, the pilot stated that when power was applied, the engine coughed and spluttered. The pilot recalled the aircraft’s airspeed at that time as about 80–85 kt. The pilot commented that the engine was left at idle longer than preferred. The pilot could not recall anything further until after the impact with the ground.

Witnesses also stated that they heard the aircraft’s engine surge twice and then silence, prior to hearing the aircraft collide with wooded terrain, about 900 m north of the threshold of runway 17 (Figure 2). None of the witnesses reported seeing the aircraft turn onto the base leg or final approach, nor the aircraft collide with terrain.

The pilot sustained serious injuries and the passenger was fatally injured. The aircraft was destroyed.

Figure 2: Aircraft wreckage. Note that the tail empennage is secured in an elevated position by being tied off to a nearby tree

Source: ATSB

__________

1. Eastern Standard Time (EST) was Coordinated Universal Time (UTC) +10 hours.
2. Runways are named by a number representing the magnetic heading of the runway.

Appendices

Appendix A – Civil Aviation Safety Authority carburettor icing probability charts

Figure A1: Civil Aviation Safety Authority (CASA) carburettor icing-probability chart annotated with Campbelltown (in yellow) and Camden (in purple) temperature information at 1630

Figure A2: CASA carburettor icing-probability chart annotated with Campbelltown (in yellow) and Camden (in purple) temperature information at 1700

Context

Pilot information

Qualifications and experience

The pilot held a valid Private Pilot (Aeroplane) Licence and a Class 2 Aviation Medical Certificate that required the pilot to wear distance vision correction and have reading correction available while exercising the privileges of the licence. The pilot reported wearing their distance correction glasses at the time of the loss of power.

No medical anomalies were identified during the pilot’s last medical examination. The pilot last completed a flight review on 1 November 2014. As of 9 June 2015, the total flying hours recorded in the pilot’s logbook was 621.8 hours, with 423.8 hours on type.

Recent history

The pilot’s spouse had recently passed away following a lengthy illness and the funeral was held on 13 July. The pilot reported not sleeping well or eating properly during this stressful period. However, the pilot stated that by 19 July they were sleeping and eating normally as the stress of the previous week had abated. More specifically, the pilot recalled obtaining about 9 hours sleep on the night prior to the accident (18 July) and commented that the sleep was normal. The pilot indicated that on the second and third nights preceding the accident (16 and 17 July), normal sleep was obtained, but that they felt tired on Saturday, 18 July. The pilot could not recall experiencing disturbed sleep or any illnesses.

There was no evidence that fatigue or the recent stressful events contributed to the accident.

A witness who interacted with the pilot on the morning of the accident stated that the pilot presented as being fine and well.

Aircraft information

The Glasair SH-2FT is a high-performance, two-seat, low-wing aeroplane constructed from fiberglass composite components. The FT model features a fixed, tricycle landing gear. The airframe was designed to provide a high top speed and efficiency of operation. Glasair indicated that the high-speed performance was complemented by a low-speed, gentle stall.

The aircraft, serial number W121, was home-built and registered VH‑HRG (HRG) in 1985. The pilot was the third owner of the aircraft since its construction.

HRG was fitted with a Lycoming O-320 engine with a hybrid ignition system and a wooden, fixed‑pitch, two-blade cruise^[3] propeller. The aircraft was issued with a Department of Civil Aviation (Australia) approved flight manual on 5 September 1988.

An estimate^[4] of the aircraft’s weight and balance showed that it was within centre of gravity limits at the time of departure and immediately prior to the accident.

Maintenance history

Examination of HRG’s maintenance records indicated that it was maintained to a day visual flight rules standard in the Private Category. The last periodic inspection was completed on 22 January 2015, and a maintenance release was issued at that time. At the time of the accident, all of the required maintenance had been completed.

Meteorological information

The meteorological conditions at Wedderburn for the flight were reported as calm with light winds. The 1700 aerodrome weather report (METAR)^[5] for Camden Airport, about 18 km to the north-west of Wedderburn Airport, stated that the weather was clear with wind from the south-east at 4 kt (about 7 km/h).

The pilot reported that the weather conditions were fine with a slight crosswind from the left on take-off.

A witness, who was airborne when HRG departed Wedderburn but had landed before HRG returned, reported experiencing a ‘little bit’ of sun glare when on the base leg of the circuit to runway 17. Geoscience Australia astronomical information^[6] showed that, at 1649, the sun would have been 2° 51.750’ above the horizon and that sunset was at 1707. The pilot reported they could not recall experiencing any sun reflection on the windscreen during the flight.

Ambient condition-related carburettor icing^[7] probability

Bureau of Meteorology weather observations at Campbelltown (Mount Annan)

Bureau of Meteorology weather observations were available for Campbelltown^[8] (Mount Annan), about 13 km north-north-west of the accident site. At around the time the aircraft departed Wedderburn Airport (about 1630), the temperature was 13.4 °C and the dewpoint^[9] temperature was 5.1 °C. This resulted in a dewpoint depression of 8.3 °C. Around 10 minutes after the accident (about 1700), the temperature was 11 °C and the dewpoint temperature was 4.9 °C. This resulted in a dewpoint depression of 6.1 °C.

Camden Airport METARs

The 1630 METAR for Camden Airport indicated an air temperature of 13 °C and a dewpoint temperature of 5 °C. This resulted in a dewpoint depression of 8 °C.

The 1700 METAR for Camden Airport indicated an air temperature of 12 °C and dewpoint temperature of 5 °C. This resulted in a dewpoint depression of 7 °C.

According to the Civil Aviation Safety Authority (CASA) carburettor icing probability chart (see appendix A), the conditions recorded at Campbelltown (Mount Annan) and Camden Airport were conducive to ‘serious’ icing at all power settings.

Pilot reports

A pilot who was flying at Wedderburn Airport at the time HRG departed reported that, as far as they were aware, they did not experience carburettor icing during their flight. However, that pilot indicated being vigilant in using carburettor heat as their aircraft was prone to such icing, and that they had applied carburettor heat on that flight.

Two other pilots who were flying at Wedderburn Airport at the time also indicated that no carburettor icing issues were experienced and that they too were vigilant in the use of carburettor heat.

The pilot of HRG reported believing the conditions affecting the flight were not conducive to carburettor icing.

Airport information

Wedderburn Airport was an uncertified, unregistered landing area about 13 km south of Campbelltown. The airport had a sealed and adjacent grass runway and was aligned 17/35 (roughly north-south) (Figure 3 inset). The airport was privately-owned and -operated. The Airservices Australia En Route Supplement Australia (ERSA) extract for Wedderburn advised the following:

• pilots should avoid flying over Appin Township (Figure 3)
• circuit traffic should avoid flying over the populous area to the north of the airstrip (refer to the section titled Wedderburn circuit pattern)
• restricted area R555 is located 1.5 NM (3 km) to the east of the airport (Figure 3).

The terrain surrounding the airstrip was heavily timbered, which provided minimal landing opportunities for an off-field forced landing.

Figure 3: Proximity of restricted area R555 (outlined by the red dashed line) to Wedderburn Airport (bottom-left of the restricted area) and Wedderburn runway 17/35 at inset

Source: Google earth, modified by the ATSB

Wreckage and impact information

On-site information

Examination of the wreckage found that, following a steep descent, the aircraft collided with trees before coming to rest about 26 m further on into a wooded area and about 20 m from a road leading to the eastern gate of Wedderburn Airport. The initial point of impact was a tree about 7 m in height. A second tree, measuring about 30–35 cm in diameter, was impacted about 17 m further along the wreckage trail. The aircraft’s angle of descent during the impact sequence with the trees was calculated to have been about 30°.

The impact sequence resulted in the engine oil sump being breached and destruction of the carburettor. The entire wing section, engine and fuselage forward section separated from the aircraft due to impact forces. The aircraft’s wooden propeller blades were broken off at the root and had shattered.

The aircraft’s landing gear collapsed and there was substantial damage to the fuel tanks and the header fuel tank was separated from the airframe. All header fuel tank plumbing was fractured. As a result of that damage, an unknown quantity of aviation gasoline leaked onto the ground under the wreckage and the amount of fuel on board prior to impact could not be determined. However, about 3 L remained in the header tank when examined.

There was no fire.

Fuel quality and quantity

Fuel quality

A number of other aircraft had refuelled from the NSW Sport Aircraft Club fuel source since 9 May 2015. A search of the ATSB’s occurrence database for the period 1 April–31 August 2015 did not identify any occurrences that could be linked to the fuel supply at Wedderburn Airport.

Fuel quantity

First responders indicated that there was a substantial amount of fuel detected at the accident site. A quantity of this fuel was recovered and tested by the ATSB. The test determined that the fuel smell and colour were consistent with Aviation gasoline 100, and that the sample was free from contamination.

The NSW Sport Aircraft Club fuel records indicated that 98 L of fuel was purchased by the pilot for HRG on 12 April 2015. This was followed by four refuels of 26 L, 24 L, 17 L and 20 L respectively on 9 May 2015 – a total uplift of 87 L. These latter fuel uplifts were consistent with a reported fuel vent line issue that resulted in the vent line being replaced. At that time, the aircraft had full fuel.

In terms of fuel quantity measurements, the owner’s manual noted that, due to the wing dihedral and location of the fuel gauge sender in the wing, the wing tank held a larger quantity of fuel than indicated by the full mark on the gauge in the cockpit. The pilot also indicated that the maximum reading on the fuel gauge was 90 L, yet the aircraft held 175 L when full (156 L in the main tank and 19 L in the header tank). Of this, about 150 L of main tank fuel was usable. There was no fuel dipstick for the aircraft.

The pilot recalled making a 40-minute flight 2 weeks prior to the occurrence flight. In contrast, the last two flights recorded on the aircraft’s maintenance release were:

• a 30-minute flight on 7 June 2015
• a flight on 14 April 2015.

That was, the only flight since the aircraft was filled to full fuel on 9 May 2015 was the 30-minute flight on 7 June 2015.

The pilot reported that the aircraft’s fuel burn rate was 30 L/hr but that 35 L/hr was used for flight planning. Using the planned fuel burn of 35 L/hr, the recorded 30-minute flight on 7 June would have burnt about 17.5 L of fuel. Based on Airservices Australia radar surveillance data, the accident flight was about 20 minutes in duration. Allowing for an additional 10 minutes for start-up, taxi and take-off, this meant that about 17.5 L was burnt on the accident flight.

The pilot reported that the main tank was selected for the duration of the flight and that the header tank was not used. The pilot further indicated that the header tank was only used if they believed the fuel was stale, and that this option was only exercised when doing the run-up checks. In this case, the estimated combined fuel burn for the flight on 7 June 2015 and the occurrence flight of 35 L meant that, at the time of the accident, there was an estimated 115 L of usable fuel in the main tank.

Technical examination of recovered items and components

The aircraft’s engine and associated components were recovered from the wreckage and transported to an approved engine overhaul facility for technical examination under the supervision of the ATSB. In addition, a number of aircraft items and components were recovered for technical examination at the ATSB’s technical facility in Canberra, Australian Capital Territory.

Conclusions

The on-site wreckage examination and post-on-site technical examinations found:

• no airframe or engine defects that may have contributed to the accident
• the main fuel tank contained a significant amount of fuel at impact
• the fuel selector was selected to the main fuel tank
• evidence of low-speed propeller rotation at impact.

The ATSB concluded that it was likely that none of engine or airframe defects or fuel contamination contributed to the loss of engine power.

Survival aspects

Shortly after the collision with terrain, witnesses arrived at the site and rendered assistance to the aircraft occupants. Witnesses reported that both occupants were restrained by at least the lap component of their seatbelt assemblies.

The pilot indicated that the passenger’s seat was fitted with a four-point harness, while the pilot’s seat was fitted with a shoulder/lap-type belt. Both seatbelts were appropriately anchored to the fuselage structure. However, due to cabin disruption during the accident sequence, the ATSB could not verify the remaining seatbelt attachment points.

The ATSB examined the survivability of the accident based on estimates of the aircraft’s speed, the impact angle and the level of aircraft disruption following the collision with terrain. The examination showed that the impact forces imparted to the occupants would normally be expected to result in serious to fatal injuries.

Additional information

Carburettor icing

Carburettor icing can occur in temperatures up to about 38 °C and is less likely in very cold climates. Increased humidity increases the likelihood of this icing. If ice continues to accumulate in the carburettor, the flow of air to the engine reduces and eventually, if the process is allowed to continue, the engine will stop.

Engines operating at reduced power settings are more prone to carburettor icing as the engine induction temperatures are lower due to the reduced airflow. In this case, the airflow through the carburettor is partially impeded by the throttle butterfly valve. This valve provides more area on which the ice can accrete and increases the partial vacuum downstream of the valve. This causes further chilling of the air and the water droplets, further increasing the likelihood of ice accretion. Unless otherwise stated in the aircraft owner’s manual, full carburettor heat should be applied prior to reduced power or closed throttle operations. The resulting warm air assists in preventing carburettor icing.

For aircraft with fixed-pitch propellers, as ice forms there is typically a small decrease in engine RPM but the engine may continue to run smoothly. As ice continues to accumulate, the reduction in RPM continues and the engine will begin to run rough. If the icing conditions are severe enough, and the pilot takes no remedial action, the engine will eventually stop.

The environmental conditions and time between the accident and the ATSB’s examination of the wreckage meant that any icing in the throat of the carburettor would have melted and not been detectable during that examination.

The pilot indicated that during the circuit, the carburettor heat was in the OFF position and the mixture was full rich. The aircraft was fitted with a carburettor air temperature gauge in the instrument panel. The pilot stated that they could not specifically recall the carburettor air temperature approaching Wedderburn Airport. The pilot also stated that checking the reading may not have been included in their normal instrument scan as icing was felt to not be a risk under the existing conditions and at that stage of the flight.

Wedderburn circuit pattern

One witness reported normally conducting the downwind leg for runway 17 closer to the runway due to the proximity of the R555 restricted area (see the section titled Airport information). Combined with noise restrictions to the north of the runway, this resulted in some pilots doing a continuous turn from downwind to base and onto final. However, another witness believed that the restricted area did not have much effect on the downwind portion of the circuit.

Several witnesses reported that they generally flew the circuit tighter than normal to avoid neighbour complaints about aircraft noise.

The pilot of HRG stated that, at Wedderburn, they normally conducted a ‘restricted circuit’, with a continuous turn from downwind to base and onto final due to the nature of the Wedderburn circuit. The pilot advised that the restricted area did not affect its conduct. The pilot of HRG further stated that members of the NSW Sport Aircraft Club, which was located at Wedderburn Airport, were aware of the need to turn onto base earlier to avoid neighbours on the closest roads to the north of the airport.

Glasair-recommended circuit pattern

The Glasair owner’s manual highlighted that the aircraft was a fast, clean aircraft that took longer to slow down than other light aircraft. Therefore, the manual recommended planning ahead and slowing down prior to entering the circuit pattern. The manufacturer recommended that entry to the circuit pattern occur at a speed between 113–122 kt. At that time, the following actions were recommended:

• the electric fuel boost pump should be turned on and the fuel tank selection changed to the desired tank
• carburettor heat should be applied for 5–7 seconds to check for icing and mixture be selected to full rich
• speed should then be reduced to 87 kt
• when abeam the landing threshold, the pilot should apply the first stage of flap (20°).

From this position, the manual recommended the pilot should:

• continue to reduce the aircraft’s airspeed
• at about 78 kt and no later than on the base leg, apply the second stage of flap (35°)
• commence the turn onto the final leg at an airspeed of about 70 kt and, if required, apply full flap (55°)
• have an airspeed of about 65 kt passing over the runway threshold.

The owner’s manual also provided a suggested pre-landing checklist. This checklist included selecting carburettor heat on and the fuel mixture to full rich.

Stall characteristics

The Glasair owner’s manual indicated that the clean stall speed for the aircraft (solo) was 55 kt, while the stall speed with flaps down at gross weight was 54 kt. The manual also indicated that stall strips were mandated on the wing inboard leading edges to induce the wing roots to stall first. The stall strips were considered by the manufacturer to be the aircraft’s stall warning indicators. Consistent with the manufacturer’s position, the Department of Civil Aviation (Australia)-approved flight manual indicated that stall warning was provided by a buffet brought on by the stall strips, which produced a steady signal about 5–6 kt prior to the stall in all configurations.

Angle of bank calculations

An aircraft in a constant, level turn develops lift greater than its weight and results in increased stall speeds. An increased angle of bank in a turn further increases the stall speed.

The minimum required angle of bank in a turn is worked out geometrically using the average ground speed and radius of turn. Due to the lack of an accurate height and position for HRG when the pilot commenced the base turn, the ATSB estimated approximate angle of bank figures using estimates of the turn radius and the pilot’s recollection of the aircraft’s speed and approximate height entering the base turn. Calculations were also done for the clean aircraft configuration and full flap stall speeds at both solo and gross weights.

All estimations indicated that the reported flying speed was above the stall speed relative to the required angle of bank.

Related occurrences

ATSB investigation AO-2014-149 - Collision with terrain involving Van’s Aircraft RV-6, registered VH-TXF, near Mudgee Airport, New South Wales on 14 September 2014

On the morning of 14 September 2014, the pilot and passenger of an amateur-built Van's Aircraft RV-6, two-seat aircraft, registered VH-TXF and operated in the Experimental category, approached Mudgee Airport. The aircraft had departed Dubbo Airport, New South Wales about 25 minutes earlier.

The pilot approached from the north-west and conducted a non-standard circuit entry including an orbit to the south of the airport. Prior to turning onto the downwind leg of the circuit, the aircraft descended to about 600 ft above ground level. Witnesses stated that the pilot conducted a tight left turn onto final approach at a slow speed and low height. The witnesses also recalled hearing the aircraft’s engine ‘splutter’ and then silence during the turn, followed by a ‘rev’ followed again by silence.

The aircraft continued its high angle of bank left turn and, at about 1053, collided with terrain about 300 m south-west and short of the runway threshold. The pilot and passenger were fatally injured and the aircraft was substantially damaged.

The ATSB found that the engine failure was probably due to carburettor icing. No defects were identified that would have precluded normal engine operation prior to the accident, and uncontaminated fuel was being supplied to the engine at that time. However, the environmental conditions at the time of the accident were conducive to serious carburettor icing at descent power, and the pilot-operated carburettor heat control was found in the OFF position.

ATSB investigation AO-2015-077 - Collision with terrain involving a Robinson R44, registered VH-VOH, 130 km east of Alice Springs, Northern Territory on 14 July 2015

On 14 July 2015, the pilot of a Robinson R44 helicopter, registered VH-VOH, was conducting aerial mustering operations on a property, about 70 NM (130 km) east of Alice Springs. At about 1300 Central Standard Time^[10], the pilot was mustering cattle along a creek system. The helicopter was at about 50 ft above ground level, when the pilot slowed the helicopter to an airspeed of about 40 kt. The pilot felt a small vibration, and initially thought it was due to loose tape on the main rotor blade. The pilot looked for a suitable landing site, but the vibration increased significantly.

As the helicopter descended, the pilot manoeuvred the helicopter through a gap between trees, and pushed the cyclic forward to maintain airspeed. The pilot lowered the collective and noticed the engine seemed to go very quiet. The low rotor revolutions per minute warning horn sounded. The pilot made a radio call to advise another pilot operating nearby that the helicopter was going down. The pilot then flared the helicopter to try to cushion the landing impact. The right skid touched down first, and the helicopter rolled onto its right side. The pilot sustained minor injuries and the helicopter was substantially damaged.

According to the Carburettor Icing Probability chart, the conditions indicated a high probability of serious carburettor icing at descent power.

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3. A cruise propeller will achieve maximum efficiency at 75 per cent power during the cruise. Take-off and climb performance will not be as good as with a climb or constant-speed propeller.
4. The ATSB could not establish the exact amount of fuel in the main or the header (or auxiliary) tanks prior to the loss of power. That fuel was estimated based on refuelling records and operational documentation from previous flights.
5. Routine aerodrome weather report issued at fixed times, hourly or half-hourly.
6. Available at www.ga.gov.au/.
7. Carburettor ice is formed when the normal process of vaporising fuel in a carburettor cools the carburettor throat so much that ice forms from the moisture in the airflow, which can restrict the airflow and interfere with the operation of the engine.
8. The elevations of Campbelltown (Mount Annan) and Wedderburn Airport are 368 ft and 850 ft respectively.
9. Dewpoint is the temperature at which water vapour in the air starts to condense as the air cools. It is used, among other things, to monitor the risk of aircraft carburettor icing or likelihood of fog at an aerodrome.
10. Central Standard Time (EST) was Coordinated Universal Time (UTC) +9.5 hours.

Safety analysis

Introduction

Following the loss of engine power, the pilot was unable to control the aircraft’s descent to an appropriate forced landing area before colliding with the ground. Due to serious injuries during the impact sequence, the pilot was unable to recall anything about the descent following the loss of power. No witnesses saw the aircraft during the base and final turns, nor the loss of control and collision with terrain.

ATSB on- and off-site specialist analyses of the engine, airframe and selected items and components did not identify any issues that could have contributed to the accident. There was also no evidence that pilot fatigue or recent stressful life events were contributory.

This analysis will examine a number of potential factors that can account for the loss of power and discuss a number of possible reasons for the subsequent loss of control.

Potential reasons for the loss of control following the engine power loss

Aerodynamic stall

The ATSB considered the possibility that the aircraft entered an aerodynamic stall prior to colliding with terrain; however, there was not enough evidence to support that hypothesis. Due to the noise abatement procedures in place at Wedderburn Airport, the circuit was reported tighter-than-normal and the pilot conducted a continuous turn from base onto final approach. Generally, a tighter‑than‑normal turn would require an increased angle of bank, increasing the stall speed. In addition, the pilot reported entering the base turn at a speed higher-than-normal.

Based on the aircraft’s estimated airspeed and angle of bank, it was determined that the aircraft remained above the stall speed throughout the base turn. Therefore, an aerodynamic stall was ruled out as a possible explanation for the loss of control.

Fuel starvation

The possibility that the header tank was selected for the duration of the flight was also considered. If full prior to take-off and used for the flight, the header tank may have run dry during the turn on to the final leg of the circuit, contributing to the loss of power and then of control.

On-site examination of the fuel selector found that it was in the mains tank position. However, this evidence is somewhat unreliable due to the potential influence of impact forces during the impact sequence.

The pilot stated that the header tank was only selected for engine run-ups and when, due to the length of time between engine starts, the fuel in the header tank might have been considered ‘stale’. The pilot stated that they always took off and flew on the mains fuel tank.

The header tank was found separated from the airframe and all fuel lines and plumbing had been fractured by impact forces. Whether the header tank was full prior to take-off, and the quantity of fuel remaining in the header tank following the impact, could not be established. In combination, these factors prevented a determination of whether the header tank was selected for the flight and ran dry during the turn onto final.

Carburettor icing

The witness accounts of two engine surges before there was silence, and the low-speed rotational signatures on the propeller, indicated that the engine lost power prior to the collision with terrain. No defects were identified that would have precluded normal engine operation prior to the power loss.

Due to the level of disruption from the impact sequence, it could not be determined if the carburettor heat was selected at the time of the accident. However, the pilot stated that they did not use carburettor heating as they believed the conditions that day were too mild for carburettor icing. The pilot also stated that the downwind leg of the circuit was conducted with the engine at idle or near idle in an effort to reduce airspeed.

In this case, the meteorological conditions around the time of the accident were conducive to serious carburettor icing at all power settings (appendix A). In combination with the reported low power setting and lack of carburettor heat, there was an elevated risk of ice accreting in the throat of the carburettor. Ice in the throat of the carburettor would have reduced the flow of air to the engine and, without pilot action to correct the situation, the engine would have stopped.

In the absence of any contrary evidence, the ATSB concluded that it was probable the loss of power during the final turn was a result of carburettor icing. The loss of power in this position would suggest that any carburettor icing remained undetected by the pilot throughout the initial legs of the circuit.

Sources and submissions

Sources of information

The sources of information during the investigation included:

• the pilot of VH-HRG
• a number of the members of the NSW Sport Aircraft Club, Wedderburn Airport
• the aircraft maintainer
• the aircraft manufacturer
• the Civil Aviation Safety Authority
• the New South Wales State Coroner
• the New South Wales Police Force
• the Bureau of Meteorology.

References

Australian Transport Safety Bureau, (2001). Melting moments: Understanding carburettor icing, Educational fact sheet.

Partie, E. and Peterson, B.D. (2009). Combating carb ice. AOPA Air Safety Foundation - Safety Brief, SB09-10/09.

United Kingdom Civil Aviation Authority. (2013). Piston engine icing. Safety sense leaflet No. 14 – January 2013.

Submissions

Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety Investigation Act 2003 (the Act), the ATSB may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to make submissions to the ATSB about the draft report.

A draft of this report was provided to the pilot of VH-HRG and the Civil Aviation Safety Authority.

A submission was received from the pilot. The submission was reviewed and where considered appropriate, the text of the report was amended accordingly.

Purpose of safety investigations & publishing information

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through: identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. Terminology An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information  Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2016 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

Safety summary

What happened

After carrying out track resurfacing and tamping works at Allandale, NSW, the Australian Rail Track Corporation Network Control Officer (NCO) granted permission for a Leighton Swietelsky Rail Joint Venture (LS Rail) tamper and ballast regulator to travel in convoy and stop before signal BN 87U near Greta. The tamper led the ballast regulator, with the Traffic Officer (TO) travelling in the rear vehicle. Near Greta, the lead track vehicle operator (operator) contacted the TO advising he was approaching a signal displaying a stop (red) indication, but that he was unable to identify the signal number. Both the TO and the operator thought that this signal was BN 87U.

The TO contacted the NCO for further instructions. During the discussion, both the operator (lead vehicle) and the TO (rear vehicle) independently established that the signal ahead was BN 83U. At about this time the tamper stopped near signal BN 83U, but the rear vehicle was still approaching from behind. The TO continued to talk to the NCO about clearing signal BN 83U, so they could continue on to signal BN 87U in preparation for stabling the vehicles at Greta.

While the TO was talking with the NCO, the TO sensed that the ballast regulator (rear vehicle) was not slowing. He looked ahead to see the gap was closing between the two vehicles. The TO noticed that the ballast regulator operator was looking at him and the TO hand gestured in a forward motion. The operator interpreted the hand gestures to mean ‘keep going’. Instead, the TO was indicating that the operator ‘look forward’. Soon after, the TO called out for the operator to ‘STOP’. The operator turned and quickly realised that the tamper was closer than he had realised and made a full brake application. However, there was insufficient time to stop before colliding with the rear of the tamper.

The collision saw the ballast regulator ride above the tamper coupler and remain supported on the tamper deck. The ballast regulator also derailed the lead axle. The tamper operator sustained a minor injury and there was moderate damage to both vehicles.

What the ATSB found

The ATSB found that the Traffic Officer’s telephone conversations distracted the ballast regulator operator, drawing his attention away from the driving task and the location of the tamper ahead. Although the operator was aware of the slowing tamper ahead, he did not maintain a safe distance between the vehicles. When the operator became aware of the stationary vehicle ahead, there was insufficient time for the operator to react and bring the vehicle to a stop before colliding with the tamper.

What's been done as a result

LS Rail has taken action to mitigate against the risk of further collisions between track maintenance vehicles, including requiring greater attention to worksite planning, briefing, communications, hazard identification and route knowledge.

Safety message

When travelling in convoy, track vehicle operators should remain alert, focused on the driving task and maintain a safe braking distance from other vehicles.

Additional safety actions

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence

Proactive safety action taken by Leighton Swietelsky Rail Joint Venture (LS Rail)

Action number:RO-2015-012-NSA-011

LS Rail have advised that actions undertaken to mitigate against the risk of further collisions between track maintenance vehicles include:

• Worksite Planning

Amend the existing planning procedure for working on multiple sites where the Traffic Officer undertakes a detailed review of the planning documents before travelling to the next worksite.

• Communication of safe working arrangements

Amend communication procedures for safe working arrangements to ensure track vehicle operators are fully aware of the travel route using track diagrams that identifies key features including controlled signals.

• Work hazard identification

Undertake a review of Pre-start/Pre-work Briefs to ensure the identification of all relevant high-risk work/hazards.

• Workforce awareness briefing

Provide awareness briefings to the LS Rail workforce to ensure the contributing factors of this occurrence is well understood and to reinforce the requirements for detailed pre-work briefings and the effects of distraction in the workplace.

• Route knowledge

Establish a LS Rail route knowledge database and the assessment criteria for Traffic Officers.

Response to Proactive safety action taken by LS Rail

Action number: RO-2015-012-NSA-011

ATSB comment in response

The ATSB is satisfied that the actions advised by Leighton Swietelsky Rail Joint Venture will reduce the risk of further collisions between track maintenance vehicles.

Context

Location

Greta is located at the 210.660 km mark^[3] on the ARTC Hunter Valley Network in New South Wales. The point of collision was near the 208.135 km, about 2.5 km southeast of Greta and about 2.4 km from Allandale. The track alignment at this location is on a sweeping curve with a 1:103 falling gradient.

Track maintenance vehicles

The ARTC had appointed LS Rail^[4] as the principal contractor for the track maintenance works. The effective control and management of the vehicles were the responsibility of LS Rail.

The track maintenance vehicles were a:

• Tamper – Plasser model 08/275 3S (fleet number DR 73114)
  • The tamper weighed about 64 t, was 20.7 m long, and was restricted to a maximum speed of 80 km/h.
• Ballast regulator – Plasser model PBR 203 (fleet number BX-045)
  • The ballast regulator weighed about 22.5 t, was 11 m long, and was restricted to a maximum speed of 50 km/h.

Both vehicles were fitted with flashing lights. The ballast regulator’s lights operate continuously and the tamper’s operate in work mode and during brake applications. The flashing lights were operating on the vehicles at the time of the collision.

An inspection of the ballast regulator brakes at the collision site found all four brake shoes were poorly adjusted. Although adjustment was required to reduce the gaps between the brake shoes and wheel treads to conform to the maintenance specification, the brakes remained operable, with the larger than specified gaps expected to have produced only a small increase in stopping distance.

Traffic Officer

The ARTC Network Rules (NSW), Work on Track – Track Vehicles ANWT 316 required the safe-working qualified worker to travel in the rear vehicle of the convoy. Duties of the Traffic Officer (TO) included notifying the NCO when track vehicles had entered or cleared a track section or running line. The rules stated that when track vehicles were travelling in convoy they:

• must travel as closely as is safely practicable
• must maintain effective communication, and
• must close up if the leading vehicle stops.

In accordance with Rule ANWT 316, the TO was travelling in the ballast regulator (the rear vehicle). The TO regularly communicated with the NCO and the tamper operator (in the lead vehicle) about the safe working arrangements.

Before the vehicles departed the Allandale worksite, the TO briefed both operators that they would be travelling up to and stop before signal BN 87U near Greta. The TO did not mention the presence or location of BN 83U signal even though this signal was shown on the Worksite Protection Plan. This omission may have lead the crews of both vehicles to believe that there were no other network-controlled signals before signal BN 87U at Greta.

Safe working arrangements

The works carried out by the tamper and ballast regulator near Allandale were part of broader track maintenance activities. The safe working method applied was a Local Possession Authority (LPA).

An LPA closes a defined portion of track for a specified period. A Possession Protection Officer (PPO) is then responsible for coordinating all the works and track machine movements. Trains, other than those authorised by the PPO, are excluded from the LPA section of track.

In this case, the TO had contacted the PPO and requested permission to travel to Greta. Permission was granted subject to the TO liaising with the NCO with regard to passing lineside signals. The TO subsequently communicated with the NCO to facilitate travel from the worksite to Greta. These actions were all consistent with the ARTC rules and procedures.

Track vehicle operator distraction

Distraction can be described as a type of inattention, where a person’s attention is diverted by a particular event or object. Operator distraction has been more specifically defined as ‘the diversion of attention away from activities critical for safe driving, toward a competing activity (occurring) voluntarily or involuntarily’^[5].

The ARTC Network Procedure ANPR 748 advises track vehicle operators to remain vigilant^[6]. That is, an operator should not engage in any activity that distracts from their attention to safety. In this case, the ballast regulator operator was aware that the vehicles would be stopping at signal BN 87U near Greta before stabling overnight. Having overheard a conversation between the TO and the tamper operator, he was aware that the tamper ahead was approaching a stop signal and that the signal was BN 83U.

At about the same time, the TO had commenced a conversation with the NCO, to facilitate the continued travel and stabling of the track machines at Greta. Expecting further instructions, the ballast regulator operator had diverted his attention to the conversation between the TO and the NCO. He also misinterpreted the TO’s hand gesturing before his attention was brought back to the driving task and looking ahead.

When the operator became aware of the stationary vehicle ahead, he immediately applied the brakes. However, given the speed of the vehicle, there was insufficient time for the ballast regulator to stop before it collided with the tamper.

Analysis of data log information from the ballast regulator showed the travel speed was 30 km/h, about two minutes before the collision. The collision was recorded as a sudden deceleration from 30 km/h to 0 km/h in less than 2 seconds.

A graph of the data also showed vertical accelerations of up to 2 g at the time of the collision – consistent with the ballast regulator riding above and then then falling onto the rear platform of the tamper (Figure 4).

Figure 4: Detail of ballast regulator resting on the rear deck of the tamper.

The ballast regulator remained overlapping and resting on the tamper’s rear deck where ancillary equipment was damaged during the collision. The ballast regulator suffered a broken front towing ‘A’ frame and a deformed front chassis cross beam. Image Source: The Australian Rail Track Corporation.

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3. All track distances in this report are referenced from the Sydney Central Railway Station.
4. LS Rail is a joint venture between Leighton Contractors and Swietelsky Australia.
5. Regan, M.A., Hallett, C. & Gordon, C.P. (2011). Driver distraction and driver inattention: Definition, relationship and taxonomy. Accident Analysis and Prevention, 43, 1771-1781.
6. ARTC ANPR 748, Transferring Track Vehicles, Network Procedures, Track vehicle operators, Section 4.

The occurrence

On 14 July 2015, a tamper and ballast regulator had carried out track resurfacing and tamping works near Allandale (New South Wales).

The section of track between Allandale and Greta was on the Australian Rail Track Corporation (ARTC) Hunter Valley corridor and was part of the Middle Hunter Train Control area. (Figure 1).

At about 1712^[1], the Traffic Officer (TO^[2]) contacted the worksite Possession Protection Officer who granted permission for both track machines to travel from Allandale on the Up Main track prior to stabling on the Up Relief track at Greta.

Figure 1: Location map

The tamper and ballast regulator had been working near Allandale before travelling in convoy to Greta.

Source: ARA/Geoscience Australia; annotated by ATSB

The NCO authorised the movement to travel to and stop at signal BN 87U at Greta (Figure 2). The TO then contacted the tamper track vehicle operator (operator) by radio, advising that they were now authorised to travel up to signal BN 87U.

At about 1714 the vehicles departed the worksite near Allandale and travelled in convoy with the tamper leading and the ballast regulator following. In accordance with Rule ANWT 316, the TO was travelling in the rear vehicle, the ballast regulator.

Figure 2: Diagram showing track layout near Greta, NSW

The tamper and ballast regulator were authorised to travel to signal BN 87U before stabling on the Up Relief track at Greta. However, signal BN 83U (about 1450m before BN 87U) was showing a stop indication, requiring both vehicles to stop. Source: Graham Vincent, Track and Signal, annotations by ATSB

As the vehicles travelled towards Greta, the operator of the lead vehicle observed a signal ahead that was displaying two red lights (a stop indication). The operator slowed the vehicle and prepared to stop, as he had not been authorised to pass any signals displaying a stop indication.

While approaching the signal, the lead vehicle operator was unable to see the signal identification sign due to the fading daylight conditions. While the operator assumed it was signal BN 87U, he contacted the TO by radio (at about 1717) and queried whether the signal immediately ahead of his position was BN 87U. The operator received a response from the TO, stating that he too thought the signal was BN 87U. The lead vehicle operator acknowledged the message and continued to approach the signal with the intention of stopping.

At about 1719, the TO contacted the NCO by telephone, to gain permission for both vehicles to pass the signal they had assumed to be BN 87U.

Meanwhile, the lead vehicle was now close enough for the operator to identify the signal, not as BN 87U but as BN 83U. Signal BN 83U was an intermediate signal located about 1450m before signal BN 87U at Greta. The operator radioed the TO, confirmed that the signal was BN 83U and asked for further instructions.

At that point in time, the TO was talking to the NCO by phone, so he could not respond to the radio communication. Consequently, the operator of the following vehicle replied to the radio communication with a ‘copy that’ response. Both operators then awaited instruction from the TO. The lead vehicle continued slowing to stop at signal BN 83U while the following vehicle continued to approach from behind.

As the ballast regulator approached the tamper, the TO continued talking to the NCO. The NCO confirmed that the signal at stop ahead was BN 83U and not BN 87U (track circuits confirmed the tamper and ballast regulator were approaching BN 83U). Having heard the radio communication from the lead vehicle operator, the TO agreed that they were approaching signal BN 83U.

While talking with the NCO, the TO sensed that their vehicle was not slowing and the gap to the vehicle ahead was closing. The TO then looked at the operator of their vehicle and noticed that he was looking back at him, rather than the track ahead.

Still talking on the phone, the TO reacted by using hand gestures to draw the operator’s attention to the vehicle ahead and that it had stopped. Although the operator had started to slow the vehicle, he assumed that the TO had received instruction from the NCO and interpreted the hand gestures to mean ‘keep going’.

It was about 1720 and the NCO was advising the TO that 112 points at Greta were set for the mainline to allow the vehicles to enter and stable on the Up Relief track.

At about the same time, the TO realised a collision was imminent and quickly called out ‘STOP’ to the operator. The operator immediately reacted by applying the service brake, however the brake application was too late and the ballast regulator collided with the rear of the tamper.

The NCO reported hearing the ‘STOP’ exclamation over the phone, followed by a ‘rumbling’ sound. About two seconds later, the phone connection terminated.

The collision occurred on a slight downhill grade, just before signal BN 83U (Figure 3). In the collision sequence, the front of the ballast regulator rode above the coupler on the tamper and came to rest partially on the rear deck of the tamper. The ballast regulator also derailed its lead axle.

Figure 3: Signal BN 83U and the Plasser tamper

Main image: Shows the location of the Plasser tamper following the collision, having previously stopped near signal BN 83U.
Inset: Signal BN 83U and its corresponding signal identification sign.
Source: Australian Rail Track Corporation and LS Rail.

Suspecting that something was not right or there had been an accident, the NCO attempted four times to call the TO to investigate. The NCO also tried to call the operator of the lead vehicle (tamper) without success. About five minutes after the disconnected phone call, the TO called the NCO to report the collision between the two vehicles. He advised that no persons were injured and that they would place protection measures on track to protect the accident site.

The ballast regulator was fitted with a data recorder that confirmed the collision speed was around 30 km/h. Both vehicles received moderate damage and obstructed the Up Main line.

The vehicles were cleared from the accident site the next day and damage to the track was minor.

The tamper operator later reported that he had a minor injury. The four employees (two operators, the TO and the NCO) were tested for the presence of drugs or alcohol. All returned negative results.

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1. Time shown as Eastern Standard Time (EST).
2. The Traffic Officer also performs the role of Protection Officer (PO).

Findings

From the evidence available, the following findings are made with respect to the collision between ballast regulator (BX-045) and tamper (DR 73114) about 2.5 km southeast of Greta, on the Middle Hunter Valley rail corridor in New South Wales.

These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Safety issues, or system problems, are highlighted in bold to emphasise their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.

Contributing factors

• The Traffic Officer’s telephone conversations distracted the ballast regulator operator, drawing his attention away from the driving task and the location of the tamper ahead.
• When the operator became aware of the stationary vehicle ahead, there was insufficient time for the ballast regulator operator to react and bring the vehicle to a stop before it collided with the tamper.
• The operator of the ballast regulator interpreted the Traffic Officer’s forward pointing hand gesture as ‘keep going’ rather than a gesture intended to draw attention to the vehicle stopped ahead.
• The Traffic Officer’s instruction and communication to the regulator operator by way of an ambiguous hand gesture was not explicit in its intended message.

Other factors that increased risk

• The briefing given by the Traffic Officer before the movement of vehicles at the Allandale worksite did not mention controlled signal BN 83U, later leading the operators to believe that the signal showing a stop indication was signal BN 87U at Greta.

Sources and submissions

Sources of information

The sources of information during the investigation included the:

• Leighton Swietelsky Rail Joint Venture,
• The Australian Rail Track Corporation,
• The Office of the National Rail Safety Regulator.

References

The Australian Rail Track Corporation, Rules (NSW), ANGE 204, Network Communication, General Rules.

The Australian Rail Track Corporation, Rules (NSW), ANPR 748, Transferring Track Vehicles, Network Procedures, Track vehicle operators.

The Australian Rail Track Corporation, Rules (NSW), Network, ANWT 316 Work on Track – Track Vehicles.

Regan, M.A., Hallett, C. & Gordon, C.P. (2011). Driver distraction and driver inattention: Definition, relationship and taxonomy.Accident Analysis and Prevention, 43, pp.1771-1781.

Submissions

Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety Investigation Act 2003 (the Act), the Australian Transport Safety Bureau (ATSB) may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to make submissions to the ATSB about the draft report.

A draft of this report was provided to:

• Leighton Swietelsky Rail Joint Venture,
• The Australian Rail Track Corporation,
• The Office of the National Rail Safety Regulator
• The operator of the ballast regulator,
• The operator of the tamper.

Submissions were received from:

• Leighton Swietelsky Rail Joint Venture,
• The Australian Rail Track Corporation,
• The Office of the National Rail Safety Regulator.

The submissions were reviewed and where considered appropriate, the text of the report was amended accordingly.

Purpose of safety investigations & publishing information

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through: identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. Terminology An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information  Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2016 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

What happened

Early in the morning on 15 July 2015, the crew of a Boeing 737800, registered VHYIU and operated by Virgin Australia International, prepared for a flight from Christchurch, New Zealand, to Brisbane, Queensland. The captain was the pilot flying and the first officer (FO) was the pilot monitoring.^[1]

The flight usually departed Christchurch at 0650 New Zealand Standard Time (NZST), but the scheduled departure was delayed on this occasion to 0815, due to a crew change. The crew change, which had been planned by the operator during the evening prior, required the captain of the flight to fly to Christchurch as a passenger that morning. The captain arrived in Christchurch at about 0730 and proceeded directly to the waiting aircraft.

Meanwhile, the FO had arrived at the airport at about 0700 and checked the flight plan package,^[2] including the flight plan, weather and NOTAMs.^[3] The FO then ordered the required amount of fuel for the flight, and proceeded to the aircraft. The FO had noticed two NOTAMs dealing with runway works at Christchurch, but assessed that neither NOTAM would affect the flight.

After arriving at the aircraft, the FO commenced normal pre-flight duties. As part of preparation for the flight, the FO prepared the take-off reference data for departure from the runway 02/A6 taxiway intersection, anticipating that the full length of the runway would be available. The FO used the 24K (24,000 lb) engine thrust rating^[4]/flaps 5 take-off reference data from the runway 02/A6 intersection table in the operator’s Airport Analysis Manual (AAM).

The captain went straight to the aircraft and met the FO. The captain then checked the flight plan, fuel load and weather information, and conducted a pre-flight inspection of the aircraft. The captain did not read the NOTAMs but was advised by the FO that there was nothing significant. The aircraft was pushed back from the gate at about 0815.

At about the time the aircraft was pushed back from the gate, air traffic control (ATC) advised the crew that there was a change in the ATIS^[5] and that runway 02 was operating at a reduced length. The reduction in runway length was associated with works in progress (WIP) that reduced the runway length available from 3,288 m to 1,920 m, with the northern 1,368 m of the runway closed (Figure 1).

Figure 1: Christchurch Airport showing runway 02 works in progress - north

Source: CAA NZ - annotated by ATSB

Before starting the engines, the crew reviewed the take-off reference data considering the revised ATIS and the reduced runway length (due to the runway works). The crew again referred to the AAM, expecting to find inserted yellow pages that provided take-off reference data to be used while runway works were in progress (see section titled Airport analysis manual). The crew found that there were no yellow pages available for Christchurch.

In the absence of reduced runway length data related to the runway works (yellow pages), the crew elected to use full thrust during the departure, and commence their take-off from the threshold of runway 02. The crew then used the 26K (26,000 lb – full rated thrust)/flaps 5 take-off reference data from the AAM that was based upon the full length of the runway being available. The FO determined the amended take-off reference speeds from the AAM, and in accordance with company procedures, the figures were cross-checked by the captain.

During taxi and while lining up on the runway, the crew did not see any personnel, equipment or obstructions on the runway. At 0827, the aircraft departed without incident.

Following departure, the crew heard ATC advise the crew of an aircraft that was inbound to Christchurch, that the full length of the runway would be available for their arrival. This prompted the captain to review the NOTAMs that had earlier been reviewed by the FO. The captain found NOTAM B3805/15 NZCH (Figure 2) referring to runway works at Christchurch, which had relevance to their flight.

From the NOTAM, the captain ascertained that the runway length at the time of their departure was reduced to 1,920 m due to WIP. The NOTAM was effective from 14 July 2015 at 2000 UTC (15 July 2015 at 0800 NZST) until 15 July 2015 at 0225 UTC (1425 NZST). The captain also noticed that there was an associated relevant company remark (immediately following the NOTAM and highlighted in Figure 2) regarding a requirement to request On-Board Performance Tool (OPT)^[6] take-off reference data during works in progress.

Figure 2: NOTAM B3805/15 dealing with runway 02 reduced length (and closure of runway 20) due to works in progress^[7]

Source: Aircraft operator, highlight added by ATSB

While still en route, the crew contacted company flight dispatch staff and requested OPT take-off reference data that should have been used during operations while runway works were in progress. The OPT take-off reference data revealed that different take-off reference speeds should have been used under those circumstances (Table 1).

The flight continued uneventfully to Brisbane. On arrival in Brisbane, the captain notified relevant airline staff of the occurrence.

Table 1: Differences between OPT take-off reference data and the data used by the crew

	OPT take-off reference data	Actual take-off reference data used
V1	142 kt	145 kt
VR	144 kt	147 kt
V2	152 kt	151 kt
Take-off weight	72,668 kg	72,490 kg
Thrust setting	26K (full rated thrust)	26K (full rated thrust)
Flap setting	Flap 5	Flap 5
Runway length	1,920 m (reduced length due to runway works)	3,288 m (full runway length)

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Take-off reference speeds

Take-off reference speeds or V speeds assist pilots in determining when a rejected take-off can be initiated, and when the aircraft can rotate, lift-off and climb. The definitions of V speeds can be quite complex, but in broad terms: V1 is often referred to as the critical engine failure speed or decision speed.

• V1 is the maximum speed at which a rejected take-off can be initiated. If an engine failure is detected above V1, the take-off should be continued.
• VR is the speed at which the rotation of the aircraft is initiated to the take-off attitude. The speed cannot be less than V1, and takes into account a number of other critical speeds that relate to aircraft performance and handling.
• V2 is often referred to as the take-off safety speed. It is the minimum speed at which a transport category aircraft complies with those handling criteria associated with climb, following an engine failure. V2 is normally obtained by factoring other critical speeds, to provide a safe margin with respect to aircraft controllability.

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Airport analysis manual (AAM)

The crew commented that a recent change in the holder of the Air Operator’s Certificate (AOC) from Virgin Australia Airlines – New Zealand (VANZ) to Virgin Australia International Airlines (VAI) had seen numerous procedural changes. The changes related primarily to the integration of VANZ and VAI procedures, to establish consistency across the company’s operations. With reference to this incident, the crew commented that prior to the change in AOC holder, AAMs included yellow pages that provided take-off reference data to be used when operating from a reduced length runway (such as during runway works). When the crew discovered that the departure runway was operating at a reduced runway length due to runway works, they initially referenced the AAM with an expectation of finding a relevant yellow page, but without that page, they elected to use 26K (full rated thrust)/full runway length data instead.

The operator’s draft report dealing with the incident commented that since the transition from VANZ to VAI, yellow pages in the AAM dealing with runway works have been removed. A note has been added to relevant NOTAMs regarding the requirement to request OPT reference data.

The flight crew commented that while a two-day training course was provided to transition crews from VANZ to VAI, the scope of the training was limited, and crews were continuing to discover procedural variations in the months following the transition. The operator advised that the course included a section on aircraft performance as well as training in AAM use. As part of their investigation, the operator reviewed relevant material presented to the flight crew and found no deficiencies, but they could not assess the efficacy of the training.

Flight plan package

The absence of yellow pages in the AAM aside, the crew expected that if OPT take-off reference data was required, it would be provided with the flight plan package. In the experience of the crew, OPT take-off reference data was usually provided with the flight plan package when required, without specifically being requested by the crew. The only reference to the requirement for the crew to request OPT take-off reference data on this occasion was a remark at the end of the NOTAM dealing with the runway works on that day. There were no other relevant prompts in the package that might have alerted the crew to the requirement to request OPT take-off reference data. Contrary to the expectations of the crew, flight dispatch staff considered that it was the responsibility of the crew to request OPT take-off reference data, when it was required.

Flight crew operational notices

During the positioning flight to Christchurch, the captain reviewed the operator’s Flight Crew Operational Notices (FCON),^[8] including the notices relevant to Christchurch. Even though there were NOTAMs in place addressing runway works, there was no reference to any runway works in the Christchurch FCON entry. In contrast, the FCON entry for Cairns, Queensland (directly before the Christchurch entry) included reference to runway works at Cairns. The Cairns entry included a statement that during the works, AAM take-off and landing data was not valid. The entry also stated:

There are no scheduled departures during the works period, however if take-off data is required request OPT …

If the FCON had included a similar reference to the runway works at Christchurch, it may have prompted the crew to review the possible implications of the runways works more closely prior to departure.

The operator advised that runway works at Christchurch were not addressed in the FCON because the anticipated time of the works referred to in NOTAM 3528/15 NZCH (see following section dealing with NOTAMs), did not conflict with the normal departure time for the flight. The operator’s investigation found that for the Cairns entry, there were also no scheduled departures during the works period, but it was close to scheduled aircraft arrival times, which required associated landing data. The operator’s draft investigation report stated that the temporary landing data for Cairns would potentially have been required daily during the works period, whereas for Christchurch the data was only required on an ad hoc basis.

The operator’s investigation found that while the aim was to avoid repeating information in a NOTAM remark and the FCON, it was not clear which was the primary source of information for the flight crew.

Notice to Airmen (NOTAM)

Pre-flight NOTAM review

The operator’s procedures required that both crew members review the relevant NOTAMs prior to a flight. The crew commented that in practice, review of flight plan material including the NOTAMs, is typically done as a team. Following a review of the material, the crew members discuss factors of relevance as part of their preparation for the flight.

Normally, the captain and FO would have met in a crew room facility to discuss the flight, before proceeding to the aircraft. However, to minimise the delay, the flight crew met at the aircraft on this occasion. The captain had limited recent familiarity with Christchurch and was unaware of the runway works, until advised by ATC during push-back.

Despite the arrangements that required the captain to travel to Christchurch during the morning of the flight, and the associated late departure, the flight crew reported that they did not feel rushed as they prepared for the flight.

NOTAMs

In addition to NOTAM 3805/15 (Figure 2), a second NOTAM B3528/15 NZCH (Figure 3), stated that works were expected to commence at 0930 UTC (2130 NZST) in the evening, and finish at 1630 UTC (0430 NZST) each morning, with a NOTAM to be issued advising of activation times. The departure time of the flight during which the incident occurred, was outside those times (both the normally scheduled and delayed departure times). As the scheduled departure time also fell outside the times specified in NOTAM 3805/15, this may have influenced the FO to expect that the works would not affect their departure.

Figure 3: NOTAM (B3528/15) dealing with runway works, identifying the expected times of runway works, and advising that activation times would be notified by separate NOTAM with the location of the works (north or south)^[9]

Source: Aircraft operator

Safety message

The operator’s investigation found that the ability to reject the take-off or maintain obstacle clearance safely in the event of an engine failure was compromised by the use of the incorrect take-off reference speeds. Inaccurate take-off reference data has potentially serious consequences. ATSB Aviation Research and Analysis Report AR-2009-052 (Take-off performance calculation and entry errors: A global perspective) documents a number of accidents and incidents where take-off performance data was inaccurate. The report analyses those accidents and incidents, and concludes:

… it is imperative that the aviation industry continues to explore solutions to firstly minimise the opportunities for take-off performance parameter errors from occurring and secondly, maximise the chance that any errors that do occur are detected and/or do not lead to negative consequences.

This incident highlights the importance of a consistency in the expectations of flight crew and the services provided by an operational support system. A disconnect on this occasion substantially diminished the defences that might otherwise have prevented the incident. In a broader sense, the incident provides an example of how changed procedures can introduce latent procedural deficiencies or misunderstandings. Robust crew training and follow-up standardisation are critical to the safe and effective introduction of new or revised operational procedures.

Aviation Short Investigations Bulletin Issue 46

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through: identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. Terminology An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information  Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2016 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

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1. Pilot flying and pilot monitoring are procedurally assigned roles with specifically assigned duties at specific stages of a flight. The pilot flying does most of the flying, except in defined circumstances. The pilot monitoring carries out support duties and monitors the actions of the pilot flying and the aircraft flight path.
2. The flight plan package was produced by the operator’s flight dispatch department at 0642 on the day of the incident.
3. A NOTAM (Notice to Airmen) advises personnel concerned with flight operations of information concerning the establishment, condition or change in any aeronautical facility, service, procedure or hazard, the timely knowledge of which is essential to safe flight.
4. 24K is a derated thrust setting. Engine thrust settings less than the maximum available thrust are often used during take-off. Take-off operations conducted at thrust settings less than the maximum take-off thrust available may provide substantial benefits in terms of engine reliability, maintenance and operating costs (FAA Advisory Circular 25-13).
5. The ATIS (Automatic Terminal Information Service) is an automated broadcast of prevailing airport weather conditions that may include relevant operational information for arriving and departing aircraft.
6. For the purpose of this report, an OPT means that the crew were required to request takeoff reference data (for departure under conditions where the runway length was reduced due to the works in progress) from the operator’s flight dispatch staff. That request could be made using on-board aircraft communication systems, or by telephone.
7. NOTAMs and other aeronautical information typically use Coordinated Universal Time (UTC) as a time reference. NZST is UTC plus 12 hours.
8. FCONs are company NOTAMs which are issued to flight crew by the flight operations department to convey new operational and technical information which is of an urgent nature. Flight crew are required to obtain and review a copy of the current FCONs at the commencement of duty each day.
9. The reference to yellow pages in this NOTAM relates to relevant Aeronautical Information Publication NZ aerodrome charts (that depict the works in progress and provide associated operational information), not the operator’s AAM yellow pages referred to elsewhere in this report.

What happened

On 14 July 2015, the pilot of a Robinson R44 helicopter, registered VH-VOH, was conducting aerial mustering operations on a property, about 70 NM east of Alice Springs, Northern Territory.

At about 1300 Central Standard Time (CST), the pilot was mustering cattle along a creek system. The helicopter was above tree height, at about 50 ft above ground level (AGL), when the pilot slowed the helicopter to an airspeed of about 40 kt. The pilot felt a small vibration, and initially thought it was due to loose tape on the main rotor blade. The pilot looked for a suitable landing site, but the vibration increased significantly.

As the helicopter descended, the pilot manoeuvred the helicopter through a gap between trees, and pushed the cyclic^[1] forward to maintain airspeed. The pilot lowered the collective^[2] and noticed the engine seemed to go very quiet and the low rotor revolutions per minute (RPM) warning horn sounded. The pilot made a radio call to advise another pilot operating nearby that the helicopter was going down. The pilot then flared^[3] the helicopter to try to cushion the landing impact. The right skid touched down first, and the helicopter rolled onto its right side.

The pilot sustained minor injuries and the helicopter was substantially damaged (Figure 1).

Pilot comments

The pilot provided the following comments:

• There was no noise to indicate that the helicopter had hit anything.
• The helicopter did not yaw when it vibrated.
• The wind was from the southeast at less than five knots, and the pilot turned the helicopter towards the east between the trees.
• The weather was fine; there were no visible signs of moisture, and only a few high level clouds.
• The pilot did not select the carburettor heat on at any stage during the flight.
• Both tail rotor blades broke off the helicopter’s tail. This may have occurred prior to striking the ground, but the pilot did not detect the helicopter tail rotor colliding with anything.

Figure 1: Accident site showing damage to VH-VOH

Source: Aircraft owner

Meteorological conditions

Weather observations from the Bureau of Meteorology’s automatic weather station at Alice Springs indicated that at 1300, the temperature was 12.9°C, relative humidity 45%, and the dew point^[4] was 1.2°C. The dew point depression, calculated by subtracting the dew point from the temperature, at that time was 11.7.

According to the Carburettor Icing Probability chart (Figure 2), the conditions indicated a high probability of serious carburettor icing at descent power.

Figure 2: Carburettor icing chart showing prevailing conditions in yellow

Source: Civil Aviation Safety Authority – modified by the ATSB

Safety message

The ATSB advises all pilots of aircraft fitted with a carburettor to check the forecast conditions and know the risk of carburettor icing prior to each flight. The carburettor icing probability chart is available on the CASA website.

The following publications provide additional information on carburettor icing:

• Melting Moments: Understanding Carburettor Icing
• Flight Safety Australia – A chill in the air
• Mornington Sanford Aviation – No ice, thank you

Aviation Short Investigations Bulletin - Issue 43

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through: identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. Terminology An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information  Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2015 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

__________

1. A primary helicopter flight control that is similar to an aircraft control column. Cyclic input tilts the main rotor disc varying the attitude of the helicopter and hence the lateral direction.
2. The collective pitch control, or collective, is a primary flight control used to make changes to the pitch angle of the main rotor blades. Collective input is the main control for vertical velocity.
3. Flare reduces rate of descent before ground impact by increasing collective pitch; this increases lift, trading stored rotor kinetic energy for increased aerodynamic reaction by blades, and should result in a gentle touchdown.
4. Dewpoint is the temperature at which water vapour in the air starts to condense as the air cools. It is used among other things to monitor the risk of aircraft carburettor icing or likelihood of fog at an aerodrome.

Safety summary

What happened

On 11 July 2015, the Melbourne to Albury service 8625 was approaching Wallan crossing loop when the train traversed the points into the loop road at excessive speed. As a result, the passengers and crew experienced a rough ride resulting in some passengers requiring medical attention from the on board service crew. The service crew reported the incident to V/Line operations and the train continued on to Seymour.

On arrival at Seymour, the train was met by a Regional Driver Supervisor (RDS). The RDS questioned the driver about the rough ride at Wallan and after a short discussion, the train departed making scheduled stops along the way.

Shortly after a stop at Euroa station, some of the passengers approached the conductor about persons in their care showing signs of discomfort and stress as a result of the earlier rough ride. The conductor decided to arrange for an ambulance to meet the train at Benalla station. Meanwhile, V/Line operations were arranging to have the driver of 8625 relieved of duty at Benalla.

On arrival at Benalla station, the conductor told the driver of 8625 that he was to be relieved of duty. Ambulance officers treated some of the injured passengers for minor injuries with one passenger and their carer taken to a nearby hospital. The service continued onto Albury with the new driver.

What the ATSB found

The ATSB found that the driver of train 8625 did not demonstrate effective train handling techniques when approaching a signal displaying a low speed aspect. As a result, 8625 traversed the points at a speed significantly greater than the allowable engineering speed.

In addition, the driver did not immediately report the severity of the incident to the ARTC train control or V/Line. As a result, the possibility of infrastructure damage exposed trains travelling on the Standard Gauge at Wallan to a potentially elevated safety risk.

The ATSB also found that V/Line did not have a procedure in place that specifically required other V/Line employees to report incidents in the event that a driver did not. Furthermore, the ATSB found that V/Line’s processes did not consider the potential for rolling stock or infrastructure damage in the event that a train had traversed a turnout at significantly greater speed than designed.

What's been done as a result

V/Line have developed and implemented a procedure, which acknowledges and addresses the risk associated with gross over-speed. They have also updated their Just Culture policy in relation to reporting and have incorporated redundant pathways to ensure reporting should a driver fail to do so.

Safety message

All incidents that could compromise the safety integrity of the network must be reported immediately to Train Control. Operators need to ensure robust reporting procedures are implemented.

For incidents that involved gross over-speed, train operators should implement procedures that identify and manage the risk appropriately.

Context

Location and track information

Wallan is located on the Melbourne to Sydney mainline about 47.5 km^[3] from Southern Cross Station Melbourne.

The track is a bidirectional standard gauge^[4] track consisting of continuously welded rail on concrete sleepers, fastened by resilient clips. Crossing loops^[5] are provided at various locations, including Wallan, to facilitate the passing or crossing of trains. The loop track is often referred to as the loop road or Number 2 road.

A railway station is located at Wallan. However, the station only services an adjacent broad-gauge^[6] track. There are no passenger facilities for standard gauge trains travelling through Wallan.

The Australian Rail Transport Corporation (ARTC) lease and manage the standard gauge track, with signal control from the ARTC Network Control Centre South at Junee (NSW).

The line speed through Wallan is 130 km/h. However, the signalled speed for the diverging route over the turnout into the loop road is 15 km/h (low speed signal).

Track inspection

Post incident track inspection at Wallan loop was undertaken by the ARTC later that evening. The track was undamaged and there was no pre-existing track condition evident that may have contributed to the rough ride.

Signalling

The signalling at Wallan loop on the standard gauge is a CTC^[7] relay based type interlocking.

The three-position signal heads used on signals ES1475 and WLN/2 were Westinghouse K3 searchlights (Figure 5). The K3 searchlight signals are a long-range signal head and have a viewing range of up to 2500 m in clean air.

Figure 5: Signal WLN2 and ES 1475

Signals WLN/2 and ES1475 taken on the 7 July after the incident during testing of the signals. Signal WLN/2 is displaying a red over red over yellow aspect (Low speed). Signal ES1475 is displaying a yellow over red aspect (Normal speed warning). Both signals are displaying the aspects that the driver would have seen approaching Wallan. The ‘A’ arms on both signals are K3 (long-range) Searchlight signals. Source: ARTC.

Signal testing

The ARTC examined the operation of signal ES1475 and WLN/2 and number 3 points at Wallan Standard Gauge Loop. The tests concluded that the signalling and points equipment were working as per design at the time of the incident.

Signal sighting and operation

The ARTC conducted an inspection on the sighting distance of the signals. Both ES1475 and WLN/2 was found to be in good working order with no issue of sighting over the designed viewing distance.

The ATSB site inspection also noted that the sighting distance from ground level for both signals was clear and unobstructed for the respective distances.

Number 3 Points and turnout

Number three points at Wallan are McKenzie and Holland M23A dual operation points.^[8] The points are on a 1 in 10^[9] turnout. The designed speed of the turnout when track conditions are optimum is 40 km/h. At Wallan however, the signalling aspect for the movement over the points is 15 km/h.

At the time train 8625 was traversing the turnout, the train was travelling at approximately 97 km/h. This was about 80 km/h greater than the signalled speed and about 55 km/h greater than the turnout design speed. As a result, there would have been significant lateral forces on the rolling stock and infrastructure as the train traversed the turnout into the loop road.

The over-speed entry into the loop road contributed to the excessive lateral forces (rough ride) experienced by the passengers and crew on-board train 8625.

Train information

The Melbourne to Albury V/Line service is a driver-only^[10] locomotive hauled passenger service consisting of an N class locomotive (N464) and an N class carriage set (SN16). Carriage set SN16 consisted of three economy wagons, a buffet car, and a first class car. There was also a parcel van/cargo carriage at the rear of the train.

In addition to the driver, train 8625 was also serviced by a crew consisting of a conductor and a service attendant for the buffet car. The conductor provided customer service and was responsible for all passenger operations and their welfare.

Rolling stock inspection and maintenance

In April 2015, Locomotive N464 underwent schedule maintenance and was returned to service in May 2015.

In June 2015, carriage set SN16 underwent scheduled maintenance and was returned to service in the same month.

On 12 July (the day following the incident), inspection of carriage set SN16 was undertake by Bombardier to determine if there was any damage as a result of the over-speed. No subsequent damage was found.

During interview, the driver stated that the train felt ok to continue and there were no issues with it as a result of the over-speed.

V/Line’s internal report concluded that there was no pre-existing condition of N464 or SN16 that may have contributed to the occurrence.

The ATSB noted that following the incident at Wallan, the passenger service ran to Albury and back to Southern Cross station the following day before being inspected for damage. While no problems may have arisen, the condition of the rolling stock was not considered until after it having returned to Melbourne.

Train Driver

The Melbourne to Albury service was operated with a driver as the sole person in the locomotive cab (driver-only operation). The driver was qualified in October 2014, to operate the driver-only service but was undergoing Train Driver Safety Audits as a result of a performance management issue.

Training

The driver of 8625 was certified competent to operate diesel hauled trains on the Southern Cross to Albury line. He had completed a written exam on 28 October 2014 and completed a route knowledge assessment on 30-31 October 2014. The assessment included completing four return trips while being supervised and assessed by a trainer driver. However, neither the written nor the practical assessments included a movement into the loop road at Wallan.

Drugs and Alcohol medical

The driver underwent testing for drugs and alcohol at Benalla Station and returned zero readings.

At the time of the incident, the driver was deemed to be medically fit for driver-only train operations.

Fatigue

The driver’s roster, sleep patterns, and general health were analysed. The investigation concluded that fatigue impairment was unlikely to be a contributing factor to this incident.

Train handling

Track speed permitted on the main line through Wallan is 130 km/h. However, V/Line mandates that V/Line trains are limited to 100 km/h.

At the time of the incident signal ES1475 was indicating a yellow aspect informing the driver that the next signal (WLN/2) was at stop. After passing ES1475 a driver should be managing the train to stop at signal WLN/2 (Figure 6).

On approach to signal WLN/2 (about 200 m prior the signal), a low speed aspect would have been visible, indicating that a route had been set for the loop road (Figure 6). The driver must be prepared to stop clear of any obstruction and not exceed a speed of 15km/h.

Figure 6: Typical speed profile versus actual speed

Figure 5 illustrates the typical speed profile for a train being signalled into the loop compared to the speed data taken from the locomotive data logger. Not to scale. Source: ATSB.

Train data logger

Locomotive N464 was fitted with a Fischer data logger device, which captured various parameters, including:

• Time, speed, distance
• Throttle position
• Brake pipe pressures
• Horn (Country and Town)
• Vigilance
• Dynamic brake

The data logger showed that on the approach to both signals the driver was making slight changes to the throttle to maintain speed of about 100 km/h (track speed). The driver also sounded the horn for the approach to Beveridge Rd and Wallan Whittlesea Rd level crossing. However, the data showed no reduction of the throttle nor brake application, at the point where a response to signals ES1475 & WLN/2 would be expected (Figure 6).

Analysis showed that the driver was managing the train in a manner consistent with being signalled straight through Wallan on the mainline. However, with the route set for the loop road, the train traversed the points at more than 90 km/h, significantly greater than the designed (signalled) speed.

The driver of train 8625 did not demonstrate effective awareness and train handling techniques consistent with approaching a signal displaying a low speed aspect.

Drivers awareness of the signalling system at Wallan

The driver had been trained on the Southern Cross to Albury section (otherwise known as route knowledge). The driver was supervised during his training and made four returned trips before being assessed as competent to drive a train on this network.

During interview, the driver was asked questions regarding the signalling at Wallan. In particular, the driver was asked about signals ES1475 and WLN/2.

The driver explained the type of aspects ES1475 would show in relation to the signal ahead (in this case WLN/2). The driver explained that if ES1475 were showing a yellow aspect, then the signal ahead (WLN/2) would be at stop^[11] (red over red).

When discussing WLN/2 signal, the driver commented that he had never been signalled into the loop track at Wallan before and that his expectation was a yellow on the “B” arm. However, at Wallan the aspect for trains to enter the loop track is in fact a “C” commonly referred to as a low speed. The driver was not aware the WLN/2 signal would show a low speed aspect for the move into the loop road and that the “B” is a fixed red^[12] aspect.

Although there may have been some confusion on what aspect the driver was expecting, when viewing WLN/2 displaying a low speed at distance, the driver would have seen a red signal (stop aspect). As such, the driver should have been preparing the train to stop at the signal. At a distance of around 200 m, the driver should have seen the ‘C’ arm low speed illuminated. Having slowed the train in preparation to stop, a driver would then proceed into the loop road at a speed no greater than 15 km/h.

Although the driver was not aware of the signal indications for the Loop Road at Wallan, the driver should have been handling the train in preparation for stopping at the signal.

Driver history

The driver of 8625 started his career in 1984 as a fireman^[13] with V/Line in Bendigo Victoria. In 1988, the driver transferred to Metro Trains in Melbourne to drive on the electrified network. In 2007, the driver returned to V/Line under the “Right of Return” agreement.

Right of return agreement

Under an agreement between V/Line and the Victorian government, a policy for ‘right of return’ was an historical arrangement dating back to the separation of electric trains and diesel services in Victoria. When the split happened drivers were told in order to complete their training they would have to transfer over to the electric trains. At the time, they were given a commitment from the Government that they could return at any time provided that V/Line was recruiting for drivers.

Under the agreement, drivers accepted back did not have to go through a recruitment process. The right of return was premised on the proviso that the driver had continuous service with electric trains and the driver had not refused re-employment with V/Line if an offer was made.

Drivers accepted under the right of return agreement were treated as a transfer. Medical records would be transferable, but the driver’s performance history was not disclosed.

Training and performance

In this case, the driver of 8625 was accepted back under the right of return agreement to V/Line in July 2007 as a Conversion Driver. V/Line acquired the driver’s medical history. V/Line also attempt to ascertain if there was any disciplinary action with Metro Trains. Due to privacy constraints, it was up to the discretion of Metro Trains or the employee to provide the information. At the time, no information was given to V/Line regarding any driver performance issues.

The driver underwent a conversion driver program, which recognised prior knowledge and experience. The driver then underwent network specific training eventually progressing to the North East network.

During the driver’s progression to operate through various networks, the driver was also undergoing performance management for various indiscretions, which included issues with inattentiveness.

Over the next six years, the driver had a number of incidents recorded against his driving record. Formal performance interviews and V/Line’s demerit point system were used to manage these incidents. Some of the incidents included SPAD’s^[14] and failure to stop at platforms. These types of incidents could be attributed to lack of concentration (inattentiveness).

The most recent incident was a SPAD in February 2014. Following this incident, the driver received a final written warning and was placed on a schedule of Train Driver Safety Audits (TDSA) and check rides.

Driver performance management

As a result of the SPAD in February 2014, (when considering the drivers prior history) V/Line issued the driver a final written notice as per V/Line’s Employee Misconduct and Discipline Procedure HRPR-33.

The driver was also required to undergo the following auditing process:

• Check rides
• 1 TDSA per month for the first six months then,
• 1 TDSA per three months for the following 12 months

Train Driver Safety Audits

V/Line Train Driver Safety Audits Policy states that:

Train Driver Safety Audits (TDSA) are aimed at ensuring that the functions associated with train driving are performed in accordance with the Book of Rules and Operating Procedures 1994, specified standards, Polices and all relevant Work Instructions and Procedures.

The policy also describes the following categories of Safety Audits as:

• Train Driver Safety Audit
• Train Drivers Safety Re-accreditation Audit
• Train Driver Promotion Assessment
• Trainee Train Driver Safety Validation
• Practical Driver Trainer Safety Audit

When considering the above categories of safety audits, the driver underwent a series Train Driver Safety Audits. The procedure explains it as:

Train Driver Safety Audit – Safety Audit conducted on all drivers that assumed the full responsibility of the position.

TDSA’s are used to monitor a drivers performance with regard to the functions associated with driving trains within the relevant rules and operation procedures on an annual basis (Train Driver Safety Audits).

Check ride

The driver underwent two separate check rides in March and April 2015 before undergoing the TDSA’s.

During the drivers first check ride over a return journey to Southern Cross Station, the auditor commented on the report that the driver;

An observation was if the driver is distracted in any way in the sense of talking on a phone or radio or having someone in the cab making conversation etc. It is my opinion that he may struggle to determine the sense of what situation he is in. i.e. speed restrictions, signals ahead at Stop, approaching platforms and how to prioritise tasks to keep the situation safe not only for himself but for others.

The second check ride was conducted over the period of two weeks. The auditor surmised in the report that;

The driver showed good concentration for all trips but I must comment that he did miss two warning boards without good reason and not centring reverser at signals after his previous misdemeanours with SPAD’s.

Train Driver Safety Audits regime

In the first 6 months all but one TSDA’s was supplied to the ATSB (June 2014 is missing).

For the following 3 months, TDSA between the month of October 2014 and June 2015 there was only one TDSA documented (June 2015). In that time, there should have been another TDSA’s sometime around February/March 2015.

The driver was currently undergoing the second phase of the TDSA regime in undertaking an audit every 3 months for the next 12 months (audits scheduled to finish around October 2015) at the time of the occurrence.

After reviewing the TDSA’s that were supplied to the ATSB none of the RDS’s undertaking the audits commented on any issues of performance such as losing concentration. In general, the driver performed without incident during the audits with the exception of a small non-conformance.

At the time of the occurrence at Wallan, the driver was still undergoing the TDSA/check ride process.

Reporting an incident

The driver of 8625 did not report the incident to (V/Line) Centrol^[15] or the ARTC Network Control. The initial report to V/Line operations was made by the buffet attendant as a result of the minor injuries suffered to passengers.

Once V/Line operations became aware of the injuries, an internal notification was sent out via text to the General Manager for Train Services and relevant staff. However, even once the extent of the over speed was known, no one within V/Line Operations immediately contacted the ARTC Network Control to notify them of the over-speed at Wallan number three Points.

V/Line reporting procedure

V/Line procedure SAPR-33 Incident and Hazard Reporting defines a Rail Safety Incident as;

A circumstance, act or omission relating to rail infrastructure or operations that had the potential to result in the death or serious injury to any person, or significant damage to property. Includes:

- Any defect in, or failure of, any part of the rail infrastructure or rolling stock and/or

- Any failure or breach of any rail operations practice, procedure, or rule.

The over-speed at Wallan constituted a Rail Safety Incident as it breached the rule of entering into the loop on a low speed at 15 km/h.

For reporting Rail Safety Incidents SAPR-33 requires that;

To report a Rail Safety Incident on V/Line or Metro Infrastructure, contact Centrol immediately (at first safe opportunity) using train to base radio or telephone:

(Note: If an incident occurs in a network not controlled by V/Line. The incident should be reported to the infrastructure managers train control via train-to-base radio. The incident must also be reported to V/Line – either via Centrol or the Report a HSE incident online form).

ARTC TA20 Section 1 General Rules state;

Rule 6b; Conditions that can or do affect the safety of rail operations in the Network must be reported promptly to the Network Controller responsible for the affected portions of the track.

Train operators are to immediately notify infrastructure owners of any incident that can compromise the safety integrity of the network to the infrastructure owner. ARTC Emergency Management procedure, TA44 requires that once an operator becomes aware of an actual incident, they are to take all necessary steps to ensure that the incident site is protected and immediately contact ARTC Network Control to ensure the protection of the network.

Incident management

At the time of the occurrence the driver attempted to ‘down play’ the incident with the V/Line NCC for fear of reprisals and asked that the RDS not be notified. However, due to the excessive speed, the occurrence increased the safety risk in relation to the network (damaged track), potential damage to rolling stock, as well as possible passenger injuries. At the time, the driver was more focussed on trying to avoid any escalation of the incident and was less focussed on the issues such as damaged track rolling stock and passenger injuries.

The driver was spoken to on the platform at Seymour by the RDS to establish the cause of the rough ride. At the time during the conversations the RDS was determining the drivers demeanour and if the driver was affected by drugs and alcohol.

The RDS understood the complexities of removing the driver from service, locating a relief driver at short notice and the possibility of cancelling the service. The RDS also understood the track speed at Wallan Loop over the points.

The RDS, while anecdotally knowing the drivers past history, did not have access to the driver’s performance history with V/Line. While this RDS does not manage this driver, to be able to make an informed decision on the driver’s capacity to continue, it would have been advantageous to have had access to, or been provided with information about the driver’s history and ongoing performance issues at that time.

In hindsight, due to the severity (speed) of the incident, the effort in trying to conceal and ‘down play’ the incident, and the driver’s prior history, the RDS should have relieved the driver at Seymour regardless of the operational issue surrounding the cancellation of the service. However, the RDS was not comfortable in respect to the organisational pressures in making such a decision without a clear policy on relieving a driver for a gross over speed.

Driver fit to continue

There is no V/Line policy for RDS’s when dealing with performance issues such as a significant over-speed to relieve the driver. The Locomotive Driver Demerit OPPR-33 policy deals with the duty of an RDS to stand drivers down on the advice of an irregularity. However, in regards to standing down a driver as a result of an over-speed, it is not specific about how to deal with an over-speed greater than 21 km/h in relation to relieving a driver.

Passenger welfare

At the time of the occurrence, passengers were thrown around the carriage with some sustaining some bumps and scalding from hot drinks. Also traveling on the service was two high dependency passengers one of which was ejected from their wheelchair. The service crew administered first aid to those passengers that requested some assistance.

When the train was at Seymour, there was no communication between conductors (those joining and leaving the service), the RDS and V/Line NCC regarding passenger welfare or any further medical assessment or assistance.

Once the service had departed Seymour, the new conductor (now on the service) was approached by concerned passengers that were caring for high dependency person(s) with concerns.

Rolling stock fit to continue

The over-speed at Wallan over the points would have placed excessive lateral loads on the track and rolling stock. The excessive lateral load could have damaged the rolling stock or track (points).

At the time, the driver considered the train safe to continue because in the driver’s opinion the train felt normal after the event. Similarly, once the RDS and V/Line operations became aware of the excessive speed that the train traversed the points there was no consideration given to the state of the rolling stock to continue. It was not until the next day that the rolling stock was examined.

__________

3. Distance in kilometres from a track reference point at Southern Cross Station.
4. The name given to the gauge of track 1435mm wide between running rails.
5. A length of track connected to the main line by switches at both ends to provide a facility that permits trains to both cross and pass each other.
6. The name given to the gauge of track of 1600mm wide between running rails
7. CTC – Centralised Traffic Control. A system of remotely controlling the points and signals at a number of interlocked stations, junctions and crossing loops in automatic signalling areas, from a centralised control or signal box.
8. Dual control points - A power operated point machine also equipped for hand operations.
9. 1 in 10 refers to the crossing rate of the turnout. The crossing rate is a measure of the angle made by the rail gauge faces at the theoretical point. The larger the crossing rate, the smaller the angle the faster the speed through the crossing.
10. Driver-only operations do not have a second person in the cab.
11. WLN/2 signal was showing a Red over Red over Yellow indication. The yellow is a low speed signal. At approach distance, the driver would only see the Red over Red signal as the yellow (low speed) is focused for a short range viewing of around 200 meters.
12. Fixed red is a signal that can only show a red aspect (single position)
13. Fireman is a term used for the second person/observer.
14. Signals Passed At Danger
15. Centrol is the V/Line train control centre.

Additional safety action

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence

V/Line

V/Line have investigated and implemented the following short-term actions:

• The HSE Incident and Hazard Reporting Procedure (SAPR-33) has been revised and updated, and the online form for reporting incidents has also been revised to facilitate easy reporting. The Just Culture Policy (SAPO-10), which emphasises reporting responsibilities, was updated in July 2015 and Just Culture awareness and training will be conducted as part of the upcoming People Manager Induction and other Awareness training.
• An Incident Response Procedure providing a clear, documented process to assist in decisions about driver relief has been revised and is in place and an interim briefing process for interim response has been delivered and implemented into daily operations.
• HSE discussed this potential issue with People & Capability staff on 10th December 2015 to ensure that the principles of Just Culture are understood and that final warning communications are delivered clearly in accordance with these principles.

V/Line have investigated and are implementing the following longer term actions:

• The operational history of existing right of return drivers will be reviewed to identify any potential 'at risk' drivers (who will be subject to safety profiling and retraining as needed). NB. Review of drivers will be prioritised according to known incident history.
• Consideration of audible warnings for approaching signals and passing lanes in the business case for the Driver Advisory System. The V/Line Rollingstock department, has taken responsibility for this Project and a Project Nomination is being developed and funding is yet to be confirmed.
• V/Line and ARTC have held discussions regarding TPWS fitment and have agreed to work together on a train enforcement solution including TPWS. The Installation of TPWS on the North Eastern Line has been included in the Network Safety funding submissions that PTV has made to government.
• A review is currently underway to consider redundant reporting pathway(s) in the event that a driver fails to report an incident.
• V/Line’s Just Culture Implementation Procedure has been updated to reflect the criticality of appropriate incident reporting.
• A Rail Resource Management training program (named ‘Operational Awareness Training’) has been developed and is currently being rolled out to all staff in operational safety roles at V/Line to promote non-technical skills development.
• A formal on call process has been introduced to ensure the correct driver relief processes are followed after confirmed or alleged incidents and relevant staff have been briefed on their requirements when responding to such incidents.
• An internal review of potentially ‘at risk’ drivers has been undertaken and these are being monitored on a case by case basis as relevant.
• In relation to tracking driver development plans, a lead has been implemented for monitoring the current database to improve date tracking.
• A new Competence Management System for V/Line drivers is under development to support appropriate management of driver competence, including the management of non-technical skill deficiencies.

Safety analysis

The driver of 8625 tried to under report the severity of the occurrence. V/Line operations then contributed to the delay in notification as a result of operational impact to services. This also contributed to the delayed reporting to the network owner.

In the first instance, a timely notification to the network owner was delayed by the driver’s attempts to cover up and under report the occurrence. Once V/Line understood the extent (speed) of the over speed, there was still a delay in notifying ARTC train control as V/Line operations was more concerned with managing the relief of the driver, ensuring minimal impact to passengers travel, and containing the train at Benalla.

At the time, there was no consideration of the fit state of the rolling stock at the time. It was not until the return of 8625 the following day to Southern Cross Station was there an inspection of the rolling stock.

Reporting a Rail Safety Incident

ARTC Emergency Management procedure, TA44 requires that any responsible rail employee must immediately report any Rail Safety Incidents that can compromise the safety integrity of the network to the network owner.

V/Line policy SAPR-33 Incident and Hazard Reporting procedure requires that the driver communicate all safety matters that can compromise the safety of the network immediately to the effected network owner or V/Line operations. However, on this occasion the driver did not report it and instead tried to downplay the incident.

The driver not immediately report the severity of the over-speed to ARTC Train Control as required under procedure SAPR-33. As a result of not immediately reporting the incident, other services running on that section of track were expose to a potentially elevated risk.

V/Line reporting procedure

During the process of information coming from the field, the RDS, conductor, and train driver were reporting back to different people within V/Line operations. However, there was no coordinated communications to a central point within V/Line operations.

When a Rail Safety Incident occurs in V/Line territory, it is reported to V/Line train control (Centrol). V/Line train control assumes not only the train control function but also (in this case) coordinates any notifications process such as emergency services.

When a Rail Safety Incident occurs in non-V/Line territory, the assumption is that the driver has made the report to the affect network owner. Once the information has been passed on to Centrol, they then notify internal stakeholders, rail regulator, and the Australian Transport Safety Bureau.

Throughout the process of a notification of a Rail Safety Incident being reporting on a network other than V/Line’s, there is no step to ensure that the affected network owner has been notified.

V/Line does not have a procedure that ensures that the affected network owner is immediately notified of an incident (Rail Safety Incident) if the driver has not reported it.

Reporting by employee

V/Line SAPR-33 HSE Incident and Hazard Reporting Procedure states that any employee or sub-contractor must immediately report any Rail Safety Incident. The policy dictates that any Rail Safety Incident must be communicated through the train driver.

Conductor Emergency Procedures also states that any communications should go through the driver. Any delays or disruptions to services can be reported directly Network Customer Centre.

There is reference to an incapacitated driver whereby the conductor would contact NCC directly. However, there is no provision to make any contact with NCC if there is an immediately notifiable rail safety incident that the driver has not reported.

V/Line had no provision in place whereby service crew may take action in the event that a driver does not (or cannot) respond appropriately to a rail safety incident.

Reporting by Network Customer Centre (NCC)

V/Line have an NCC Incident Escalation Procedure OPPR-57 on the reporting and escalation of a safety incident. The procedure defines a serious incident and the communication protocol.

There is no specific requirement to ensure that the relevant network owner (ARTC) has been notified of a serious incident. By definition of the procedure OPPR-57, a safety issue that can affect the network is required by SAPR-33 and ARTC’s TA 44 to be immediately reported.

V/Line’s policy SAPR-33 requires that the driver is to inform the infrastructure owner regarding any incident as well as V/Line NCC. As a result of the non-reporting of the occurrence by the driver, ARTC Network Control was not immediately notified.

The ARTC Network Control was contacted on two separate occasions by V/Line operations and on the third occasion (75 minutes after the incident) was formally notified of the over speed event at Wallan.

Any incident the compromises the safety integrity of the network must be report directly to the infrastructure owners Train Control. As a result of the delay, a freight and inter-rail service had passed over the section of track (points) of the over-speed exposing the services to a potentially elevated risk.

Even after NCC was aware of the incident, there were no steps in place to ensure that ARTC was aware of the incident.

V/Line’s procedure OPPR-57 Cars (NCC) Office Escalation Procedure did not include a requirement to contact the infrastructure manager in the event that the assessed severity of an incident had escalated.

Rolling stock fit to continue

V/Line consideration of a gross over speed is in relation to the driver demerit points system (driver performance). As a result, V/Line did not understand the risk associated with a gross over-speed (greater than 21 km/h) when considering the rolling stock.

V/Line did not have an effective procedure in place to reduce the risk when dealing with the management of a gross over-speed incident. With no procedure in place the train was allow to continue on as the operational staff directly involved with the service could make a determination on how to best manage the incident.

As a direct result of having no procedure (guidance) and not considering the risk, V/Line allowed the train to continue. The result of allowing the train to continue exposed passengers and other network users to risk as the rolling stock had not been considered for its fitness to continue.

V/Line’s processes did not consider the potential for rolling stock damage in the event that a train had traversed a turnout at significantly greater speed than designed.

The occurrence

At 1802^[1], on 11 July 2015, V/Line passenger train 8625, departed Southern Cross Station (Melbourne, Victoria) for a scheduled service to Albury (New South Wales).

Shortly after departing Southern Cross Station, train 8625 stopped on the passing loop at Tottenham and waited for a freight service to pass on the main line. Train 8625 then continued onto Broadmeadows for its first scheduled stop. At about 1840, train 8625 departed Broadmeadows, bound for its next scheduled stop at Seymour (Figure 1).

Figure 1: Location map – Wallan, Seymour, Benalla Victoria

Source: NatMap Railways of Australia

At about 1845, the Australian Rail Track Corporation (ARTC) Network Control Officer (NCO) had set the signals at Wallan (Figure 1) for train 8625 to take the passing loop, allowing an oncoming Melbourne bound train to pass on the main line. This action set number 3 points for the passing loop and then the signal interlocking cleared signal WLN/2 for a low speed entry into the loop track. Signal WLN/2 is located about 50 m from the turnout (number 3 points) and signal ES1475 about 3.5 km from the turnout (Figure 2).

Figure 2: Signalling approaching Wallan

The above schematic shows the position of the signals, level crossings, and points. The signals show the aspects at the time of the train approaching ES1475 and WLN/2. Not to scale. Source: ATSB

At about 1858, train 8625 approached signal ES1475 displaying a yellow aspect and passed it travelling at about 104 km/h. It was just after sunset and it had been raining intermittently. The driver continued on to Wallan, managing the train’s throttle to maintain a speed of about 100 km/h.

About 2 minutes later, train 8625 approached and passed signal WLN/2 signal displaying a low speed aspect (Figure 4). At about this point, the driver placed the train’s throttle into the idle position. At the time, the train was travelling at a speed of about 98 km/h.

Shortly after, train 8625 crossed over number 3 points and onto the loop track, travelling at about 97 km/h. The train swayed violently, severe enough that some of the passengers were thrown out of their seats. About 5 seconds after passing over the points (a distance of about 185 m), the driver made a service brake application. The train stopped about 1.5 km later, at WLN/U6 signal (Figure 3) in readiness for its departure.

Figure 3: Layout of signalling at Wallan loop Standard Gauge.

Figure 3 shows the location of the signalling. Train 8625 arrived at Wallan from Melbourne (from left of figure 3) Once 8625 traversed the number 3 points the train came to a stand at WLN/U6 signal on the loop track (No.2 road) waiting for train 6WP2 to approach from the Seymour (right side of Figure 3) on the main line (No.1 road). Source ARTC

Figure 4: Approaching WLN 2 signal and 3 points into Wallan Loop road.

Figure 4 shows the location at and beyond WLN/2 signal over Wallan Whittlesea Rd and approaching 3 points with the signal and points set for the loop road. Note the low speed aspect (yellow) on the ‘C’ arm. At the time, 8625 was travelling over 90 km/h. The top right call out box shows number 3 points in the reverse position and the loop road diverging to the right hand side. The lower right hand call out box show the track layout beyond 3 points through the cripple road points (right hand side). Train 8625 was traversing the middle road (Figure 3 No.2 road) after traversing 3 points in reverse. Source: ATSB

After stopping at signal WLN/U6, the driver contacted the conductor to apologize for the rough ride into the loop road. The conductor responded on the radio that they were attending to some of the passengers who had been thrown out of their seats. At that time the driver of train 8625 did not contact ARTC NCO to advise of the occurrence.

Post incident

At about 1905, freight service 6WP2 passed through Wallan on the main line and continued over number 3 points towards Melbourne. There was no report from the crew to the ARTC Network Controller regarding any rough ride over number 3 points at Wallan.

Shortly after the passage of 6WP2, signal WLN/U6 (Figure 3) cleared to proceed and train 8625 continued on towards Seymour.

As the train continued towards Seymour, the buffet car attendant contacted the V/Line Network Customer Centre^[2] (NCC) to report the rough ride incident on the 8625 Albury service and that passengers had been shaken up. The buffet car attendant then contacted the driver via the radio and asked him to also talk to the NCC regarding the incident.

The driver contacted the NCC and advised that he went a bit quick over the points at Wallan, but that everything was OK. The operations officer enquired about the passenger injuries and informed the driver that the Regional Driver Supervisor (RDS) would be notified. The driver asked that the incident not be reported to the RDS, but the NCC explained that it was protocol to report incidents causing injuries, via text message, to the RDS as well as other appropriate staff within operations.

Meanwhile, a relief service crew (excluding driver) were waiting to join train 8625 at Seymour station. The buffet car attendant on train 8625 contacted Seymour station to advise the relief service crew that there had been a rough ride event and to keep an eye on the passengers when they took over the service. At about the same time, the NCC contacted the on-duty RDS, who was also located at Seymour, and requested the RDS meet the train to enquire further with the driver regarding the incident.

At about 1940, train 8625 arrived at Seymour and the relief service crew boarded the train. The conductor joining the service noticed that some of the passengers disembarking from the train were in some discomfort. He talked to the outgoing conductor who informed about the condition of the remaining injured passengers, including a passenger in a wheel chair that had also sustained an injury. Passengers also remarked to the conductor about the violent nature of the event.

The RDS also met the driver at Seymour and discussed the reported rough ride at Wallan. The driver informed that the train was going a bit quick over the points at Wallan. The RDS was not aware that the train was in fact traversing the points into the loop road at the time of rough ride. The RDS advised the driver to be careful of his speed and to slow down. As the RDS walked away, an off-duty driver travelling on the train approached the RDS and explained that the service was signalled into the loop road at Wallan. The RDS re-engaged with the driver and verified that the train was signalled into the loop road at Wallan. Upon ascertaining that the train was going into the loop road, the RDS acknowledged that the move into the loop road was a low speed and that driver was going too fast for the move over the points. The RDS then reiterated to the driver to slow down and take more care on the rest of his journey.

At about 1944, train 8625 departed Seymour to continue its journey, with scheduled stops at Avenel, Euroa, and Violet Town.

Meanwhile, the (V/Line) General Manager Train Services contacted the RDS to discuss the situation. A decision was made for the RDS to relieve the driver of train 8625.

The RDS departed Seymour by taxi and travelled towards Violet Town to meet and take over control of the service.

Shortly after at about 1955, Melbourne bound freight service 7MP7 was travelling through Wallan on the mainline. There was no report of 7MP7 experiencing any rough ride as it passed through Wallan and over number 3 points.

While on route to Violet Town, the RDS contacted the ARTC NCO to request that train 8625 be held at Violet Town to relieve the driver. At that time, the NCO had not been advised of the incident that had occurred at Wallan.

After some further consideration, V/Line operations decided to hold the train at Benalla (about 25 km past Violet Town) to avoid disrupting passengers transferring to a bus service and to avoid blocking the town’s main road over the railway tracks. The RDS contacted the ARTC Train Control and advised that the train would be held at Benalla instead of Violet Town. Again, the NCO was not told of the incident at Wallan.

Shortly after, the RDS contacted ARTC again to inform the NCO of the incident at Wallan regarding the over-speed (rough ride) over the points. In response, the NCO advised that they would slow further trains through Wallan until the points (track) at Wallan could be inspected for damage.

As train 8625 continued towards Benalla making its scheduled stops, the service crew attended to the remaining passengers who were in various levels of discomfort. At about 2046, when between Violet Town and Benalla, the conductor was made aware of a high dependency passenger that was in some discomfort caused by a knock to the head during the incident. The passenger’s carer requested that an ambulance attend to the person. The conductor placed a call to the Emergency Services Telecommunications Authority (ESTA commonly known as ‘000’) and requested that an ambulance meet the train at Benalla station to attend to the injured passengers.

Soon after, another passenger approached the conductor concerning a possible injury to their child. The conductor informed the passenger that an ambulance was meeting the train at Benalla where passengers would be assessed.

Not long after placing the call to ‘000’, the conductor then returned a missed call to his manager. The manager informed the conductor that they could not contact the driver via radio or phone, and asked about the driver’s general demeanour. The conductor advised that the driver’s behaviour had appeared normal. The manager asked the conductor to approach the driver at Benalla to advise that the RDS was on the way to take charge of the train.

Train 8625 arrived at Benalla at about 2053, about the same time as the ambulance. Some of the injured passengers left Benalla on a connecting bus service without seeking treatment, noting also that some had left the service prior to Benalla. The remaining injured passengers were treated at the station and it was decided to convey one person to hospital for further observation.

Meanwhile, the conductor radioed the driver and asked to speak to him at the front of the train on the platform. The conductor informed the driver that he was not to continue and that the RDS was coming to relieve him.

Shortly after the RDS arrived at Benalla and performed an alcohol breath test on the driver. The driver then returned to Melbourne by taxi.

At about 2135, train 8625 continued to Albury under the control of the RDS.

At about 2200, ARTC track and signal maintenance staff arrived at Wallan to inspect and test the signalling. About an hour later, maintenance staff reported to ARTC train control that the equipment and track had been tested ok and was clear for normal traffic to resume. The temporary speed restricted on that section of track was removed and services through the area returned to normal.

The rolling stock was not examined for any damage until the train had returned to Melbourne the following day. The inspection did not find any damage as a result of the over-speed entry at Wallan.

__________

1. The 24-hour clock is used in this report. Local time was Eastern Standard Time (EST)
2. The V/Line Network Customer Centre (NCC) provides operational support to V/Line passenger trains on the ARTC rail network, but does not provide train control services on the ARTC rail network.

Sources and submissions

Sources of information

The sources of information during the investigation included the:

• V/Line
• ARTC
• Emergency Service Telecommunications Authority (ESTA (000))

References

RISSB Glossary of Railway Terminology – Guidelines Vol 1 2010

Westinghouse Brake and Signal product information for Searchlight Signals Style K2 & K3

V/Line Just Culture Policy SAPO-10 14/1/2013

V/Line Locomotive Driver Demerit System Procedure OPPR-33

V/Line Train Driver Safety Audits procedure OPPR-15

V/Line Train Driver Safety Audits checklist OPFO-13 Rev10

V/Line Position Description for Conductors

V/Line internal report into the over-speed at Wallan 11 July 2015

V/Line Conductor Emergency Procedures Conductor Training May 2015

V/Line Employee Misconduct and Discipline Procedure HRPR-33 Rev 8

V/Line HSE Incident and Hazard Reporting SAPR-33

V/Line NCC Incident Escalation Procedure OPPR-57 Rev 2

V/Line memo; VPO386-Speed Restrictions on North East Standard Gauge

Turnout design and components. Robin Stevens Queensland Rail

TA20 Section 2 Fixed Signals 4 October 2015 Rev 2

TA20 Section 1 General Rules 4 October 2015 Rev 2

Submissions

Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety Investigation Act 2003 (the Act), the Australian Transport Safety Bureau (ATSB) may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to make submissions to the ATSB about the draft report.

A draft of this report was provided to the Australian Rail Track Corporation, V/Line, the driver of 8625, and the Office of the National Rail Safety Regulator.

Submissions were received from Australian Rail Track Corporation, V/Line, the driver of 8625, and the Office of the National Rail Safety Regulator. The submissions were reviewed and where considered appropriate, the text of the report was amended accordingly.

Findings

From the evidence available, the following findings are made with respect to the over-speed that occurred at Wallan Crossing Loop on the standard gauge 47 km north of Southern Cross Station by rail in Victoria, on 11 July 2015. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Safety issues, or system problems, are highlighted in bold to emphasise their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.

Contributing factors

• The driver of train 8625 did not demonstrate effective awareness and train handling techniques consistent with approaching a signal displaying a low speed aspect.
• Train 8625 traversed the points at a speed significantly greater than the engineering speed, contributing to the excessive lateral forces (rough ride) experienced by the passengers and crew.

Other factors that increased risk

• The driver did not immediately report the severity of the over-speed to ARTC Train Control as required under procedure SAPR-33. As a result of not immediately reporting the incident, other services running on that section of track were expose to a potentially elevated risk.
• V/Line does not have a procedure that ensures that the affected network owner is immediately notified of an incident (Rail Safety Incident) if the driver has not reported it.
• V/Line had no systems in place whereby service crew may take action in the event that a driver does not (or cannot) respond appropriately to a rail safety incident.
• V/Line’s OPPR-57 Cars (NCC) Office Escalation Procedure did not include a requirement to contact the infrastructure manager in the event that the assessed severity of an incident had escalated.
• V/Line’s processes did not consider the potential for rolling stock damage in the event that a train had traversed a turnout at significantly greater speed than designed.

Other findings

• All signalling associated with incident at Wallan Loop was tested after the incident and found to be working as per design with no signal sighting issues.
  • The V/Line internal report determined that there was no pre-existing defect with the rolling stock that may have contributed to the rough ride.
  • There was no pre-existing track condition evident that may have contributed to the rough ride.

Purpose of safety investigations & publishing information

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through: identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. Terminology An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information  Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2017 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.