What happened

On 8 March 2015, the pilot of an Aero Commander 500 aircraft, registered VH-WZV, prepared to conduct a charter flight from Badu Island to Horn Island, Queensland, with five passengers. The aircraft had been refuelled earlier that day at Horn Island, where the pilot conducted fuel drains with no contaminants found. He had operated the aircraft for about 2 hours prior to landing at Badu Island with no abnormal performance or indications.

At about 1330 Eastern Standard Time (EST), the pilot started the engines and conducted the standard checks with all indications normal, obtained the relevant clearances from air traffic control, and taxied for a departure from runway 30. As the pilot lined the aircraft up on the runway centreline at the threshold, he performed a pre-take-off safety self-brief and conducted the pre-take-off checks. He then applied full power, released the brakes and commenced the take-off run. All engine indications were normal during the taxi and commencement of the take-off run.

When the airspeed had increased to about 80 kt, the pilot commenced rotation and the nose and main landing gear lifted off the runway. Just as the main landing gear lifted off, the pilot detected a significant loss of power from the left engine. The aircraft yawed to the left, which the pilot counteracted with right rudder. He heard the left engine noise decrease noticeably and the aircraft dropped back onto the runway. The pilot immediately rejected the take-off; reduced the power to idle, and used rudder and brakes to maintain the runway centreline.

The pilot initially assessed that there was sufficient runway remaining to stop on but, due to the wet runway surface, the aircraft did not decelerate as quickly as expected and he anticipated that the aircraft would overrun the runway. As there was a steep slope and trees beyond the end of the runway, he steered the aircraft to the right towards more open and level ground. The aircraft departed the runway to the right, collided with a fence and a bush resulting in substantial damage (Figure 1). The pilot and passengers were not injured.

Figure 1: Damage to VH-WZV

Source: Aircraft engineer

Engineering inspection

An engineering inspection was carried out following the incident. The engineer reported that both engines started and ran without problems and that he ran both engines to full power for sufficient time to establish that there were no obvious defects with the engines and that both engines produced full power. The magneto drop checks were within limits and fuel flows were normal. Both engines appeared to be in their normal configuration with the appropriate quantities of oil and no defects were noted.

The engineer also reported that there was adequate fuel on board the aircraft, and no contaminants were present in the fuel. The engineer verified that the propeller operation and feather checks were functional.

Pilot comments

The pilot reported that the fuel for both engines was selected to ON. At no time had either been selected to OFF, as it was not normal procedure to switch the fuel off when shutting the aircraft down.

Operator report

A report prepared by the aircraft operator, and provided to the ATSB, included the following:

• Due to the prevailing conditions of a wet runway and the extremely powerful brakes fitted to the aircraft type, the wheels locked up and the aircraft skidded off the end of the runway. The operator stated that it was easy to aquaplane or lock the brakes in wet or emergency situations.
• The aircraft was loaded within the weight and balance limitations and was 67 kg below the take-off weight for the available runway length, based on the approved performance charts.
• Passengers on the flight commented on a problem with the left engine at the time of the incident.
• Further engineering assessment of the engine and ancillaries will include fuel on board, fuel pumps (engine driven and electric), fuel control unit, magneto ignition systems, engine air intake system and other systems likely to contribute to a loss of engine power.

Safety message

In this incident the pilot had identified the safest run-off area in the event of an engine failure. Having completed a thorough pre-take-off safety briefing, following partial engine failure, the pilot was able to steer the aircraft to a relatively clear area that he had identified. This may have reduced the amount of damage the aircraft sustained, and the potential for injuries to the pilot and passengers.

The ATSB publication Avoidable Accidents No. 3 – Managing partial power loss after take-off in single-engine aircraft, states that a pre-flight safety brief, including planning a rejected take-off, gives pilots a much better chance of maintaining control of the aircraft, and helps the pilot respond immediately in the event of a partial loss of engine power.

Aviation Short Investigations Bulletin - Issue 41

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

On 28 February 2015, at about 1232 Eastern Standard Time (EST), an Enstrom 280 helicopter, registered VH-YHD (YHD), departed from Caloundra Airport, for a flight to Redcliffe Airport, Queensland, with the pilot, who was the only person on board.

After about half an hour, the pilot commenced a descent from 1,500 ft above ground level (AGL). The pilot then broadcast on the Redcliffe common traffic advisory frequency (CTAF) that YHD would join the Redcliffe circuit in about 6 minutes and navigated along the coastline toward Redcliffe.

At about 1,000 ft AGL, the pilot heard a bang and the engine stopped. This caused the helicopter to yaw to the left violently. The pilot then attempted to restart the engine but was unsuccessful. At about 800 ft AGL, the helicopter entered autorotation^[1] and the pilot prepared to land on the beach. The pilot observed people swimming in the sea and manoeuvred the helicopter to an area where there were no people. The pilot arrested the descent and the skids contacted the sand. The helicopter continued to move forward along the sand, and then a few seconds later the helicopter blades impacted the sand, and the helicopter rolled over. The pilot received minor injuries and the helicopter was destroyed (Figure 1).

Figure 1: Accident site showing the damage to VH-YHD

Source: Queensland police

Witness

A witness to the accident reported that the helicopter was first sighted at about 100 m above the ground, descending and approaching from the north. The only noise was from the rotor blades, with no engine sound. The witness reported that the wind was quite strong coming from the east. A stronger easterly gust came when the helicopter was close to the ground. The helicopter landed and continued to move forward, but then flipped upside down and the rotor blades contacted the sand. The helicopter came to rest about 150 m from where the witness was located. A passer-by assisted the pilot to exit the helicopter.

Pilot comment

The pilot provided the following comments:

• This was the first flight after the completion of the periodic (100 hourly or 12-month) maintenance inspection.
• The helicopter operated normally during the engine run-up checks and the flight, up to the engine failure.
• The pilot commented not to delay in lowering the collective^[2] and setting the airspeed as everything happened very quickly after the engine failed and the pilot instinctively conducted an autorotation.
• The landing was smooth with no bump.
• The weather was fine with a slight breeze from the north-east and the wind speed at Caloundra was about 10 kt.
• Rather than fly direct to Redcliff airport the pilot had selected to fly along the shoreline. If YHD had flown direct to Redcliff then the engine may have failed over Deception Bay and YHD may have landed in the water.
• The pilot stated that the number of flight hours experience on the helicopter type was about 60, with about eight flight hours on the type in the 90 days prior.

Helicopter maintenance

The helicopter engine was overhauled and installed in YHD in April 2006. At the time of the accident, the engine had completed about 146 hours since overhaul. The periodic (100 hourly or 12-month) maintenance inspection included overhaul of the engine magneto.

Maintenance organisation investigation

The maintenance organisation inspected the engine externally and removed the number three cylinder. They determined that the damage found to the number three cylinder and piston (Figure 2) was consistent with detonation. Extreme heat from uncontrolled burning of the combustion gases resulted in melting of the cylinder between the spark plug hole and the exhaust valve seat. This melting damaged the piston to an extent that the combustion gases would blow past the piston rings. The maintenance organisation did not remove the other cylinders.

The maintenance organisation also removed the engine magneto and fuel control unit. Both units were examined at a component overhaul facility. The examination of the magneto found no defects. The examination of the fuel control unit found that it was functioning normally and was set to a lean position, although this position could not be validated due to disruption during the accident.

Figure 2: Damage to number three cylinder and piston

Source: Aircraft maintenance organisation

ATSB comment

In 2007, the ATSB published an aviation safety research and analysis report, Aircraft Reciprocating-Engine Failure An Analysis of Failure in a Complex Engineered System B2007/0191. The safety study discussed detonation in more detail including the examination of the factors that contribute to detonation free - operation (normal combustion) and the factors that contribute to detonation.

Safety message

When planning a particular flight it is important for pilots to consider options and risk. In this accident, the pilot opted to follow the coastline, allowing for the option to land on the beach. The pilot in the pre-flight planning identified the hazard (flying over water) and although the likelihood of an engine failure was low, the consequences were high and made the decision to follow the coastline to mitigate the risk. If the pilot had selected the option to fly the most direct path then the engine would have failed over the water.

The US Federal Aviation Administration (FAA) has published information on risk management in a Risk Management Handbook (FAA-H-8083-2). They have also published a guide Tips for Teaching Practical Risk Management and Practical Risk Management for local VFR Flying. The guide contains the Perceive-Process-Perform model that offers a structured way to manage risk for local visual flight rules flying (Figure 3).

Figure 3: Risk Management Decision Path: Perceive-Process-Perform

Source: US Federal Aviation Administration

Aviation Short Investigations Bulletin Issue 44

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. Autorotation is a condition of descending flight where, following engine failure or deliberate disengagement, the rotor blades are driven solely by aerodynamic forces resulting from rate of descent airflow through the rotor. The rate of descent is determined mainly by airspeed.
2. Collective is the primary helicopter flight control that simultaneously affects the pitch of all blades of the lifting rotor. Collective input is the main control for vertical velocity.

On 10 February 2015, a Drifter and a Thruster ultralight aircraft, recreational registration 25-0452 and 10-0339 respectively, both collided with terrain approximately 7km south of Donnington Airpark, near Townsville, QLD.

Recreational Aviation Australia (RA-Aus) is the organisation responsible for investigating this accident. As part of its investigation, RA-Aus requested technical assistance from the Australian Transport Safety Bureau (ATSB) in the examination of physical components from the involved aircraft. To protect the information supplied by RA-Aus to the ATSB and the ATSB's investigative work to assist RA-Aus, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

Results of a visual examination of the physical components were provided to RA-Aus on 8 April 2015.

Enquiries relating to this occurrence should be directed to Recreational Aviation Australia.

Safety summary

What happened

At about 0513 on 12 March 2015, the driver of a Sydney Trains A-set passenger train operated the train in the wrong running direction from Mt Druitt station. Instead of travelling towards St Marys on the Down Suburban line, he drove 761 m in the opposite direction towards Blacktown. The driver only braked after a network control officer (NCO)^[1] contacted him and told him to stop. At the time, only the driver and guard were on board.

At the same time, a Pacific National freight train was about four kilometres away and travelling towards the passenger train on the same line. The NCO also called the driver of the freight train and told him to stop. There were no injuries or damage as a result of this incident.

What the ATSB found

The ATSB found that a number of factors contributed to the driver losing awareness of the way the train was facing. It was likely the driver was:

• confused about the direction due to changing ends seven times
• distracted from the main task of driving as he had spent over 3 hours at Mt Druitt station performing other tasks before he started driving
• at risk of making an error due to his high workload
• feeling under pressure to move the train
• impaired by fatigue due to being awake for over 21 hours and in the low range of the circadian sleep cycle.

Sydney Trains fatigue management processes were ineffective in identifying the fatigue impairment experienced by the driver.

The guard did not take any action to stop the train although the guard was aware that the train was running in the wrong direction.

What's been done as a result

Sydney Trains conducted an internal safety investigation and is implementing several safety actions in response to that internal report.

Safety message

Rail operators should ensure that adequate strategies exist to safeguard against fatigue impairment of train crew. It should also be noted that train crew have a responsibility to decline a shift if they feel that their performance may be affected by fatigue.

SydneyTrains A-set

Source: OTSI

__________

1. Network Control Officer - A Competent Worker who authorises, and may issue, Occupancy Authorities, and who manages rail traffic paths to ensure safe and efficient transit of rail traffic in the Network. (Sydney Trains - RailSafe Glossary)

Context

Incident location

The incident occurred at Mt Druitt station on the Down Suburban line. Mt Druitt is located 43 km west of Sydney (Figure 2).

Figure 2: Location of incident at Mt Druitt

This map shows the major railway lines in the Sydney metropolitan area including the western line where the incident occurred.

Source: Geoscience Australia

There were four platforms and four standard gauge lines at Mt Druitt station, the Up and Down Suburban lines and the Up and Down Main lines. Platform 3 is next to the Down Suburban line (Figure 3).

Figure 3: Line information Mt Druitt

The red arrow shows the direction that train 165-S travelled on the Down Suburban line.

Source: OTSI

Train information

Sydney Trains operated the train involved in the incident. The set number of the train was A19. On the day of the incident, it was completing run 165-S. The A-set or Waratah train is an electric multiple unit. It consisted of eight cars with a driving car at each end (Figure 4), two motor cars located next to each driving car, and two trailing cars in the centre of the train. Waratah trains first entered service on the NSW rail network in 2011.

Figure 4: A-set driving car

Source: Sydney Trains

Crew information

The driver and guard were based at Central station, Sydney. Both lived in the inner suburbs of Sydney and had less than 30 minutes travel time to work.

The driver was an experienced driver, starting as a metropolitan train driver in April 2005. He was familiar with the route, fully qualified and medically fit.

The guard was less experienced, having started as a guard in June 2013. The guard was qualified and medically fit.

The driver and guard had not previously worked together.

Environmental conditions

The storm that had caused the network delays the previous evening had long since passed by the time of the incident. Other than some rain showers between 0248 and 0258, there were no adverse weather conditions.

The overnight minimum temperature was 17.5°C as recorded by the Bureau of Meteorology at Horsley Park, approximately 10 km from Mt Druitt station.

It was still dark when the incident occurred at 0513. Sunrise was at 0553.

Network management

NCOs in the Blacktown, Penrith, and St Marys signal boxes control train movements in the area around Mt Druitt. The train controller in the Rail Management Centre at Central also has visibility of train movements throughout the network.

Train maintenance

A private company, Downer Rail, was the contracted entity responsible for A-set train maintenance at the time of the incident. On the morning of the incident, a train technician from Downer Rail attended the site and assisted the driver to restart the train. He left before the driver moved the train.

Findings

From the evidence available, the following findings are made with respect to the wrong running direction of a Sydney Trains passenger service, 165-S, that occurred at Mt Druitt, NSW on 12 March 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 lost awareness of the direction he was to travel due to changing ends seven times in 3 hours while dealing with tasks not usually associated with driving while the train was stationary at Mt Druitt station.
• The driver spent over 3 hours at Mt Druitt station performing other tasks before he started driving, his focus of attention directed at fixing problems with the train. When he departed, it was likely his mind was still engaged with the previous task.
• The driver experienced a period of sustained high workload during his time at Mt Druitt station in the hours leading up to the incident.
• The driver felt that he was under pressure to move the train after receiving multiple telephone calls questioning when he would be moving.
• It is likely that the driver of train 165-S was experiencing some level of fatigue impairment when he started driving the train in the wrong running direction.
• The time of day when the incident occurred is known to be in the low range of the circadian sleep cycle.
• Sydney Trains' fatigue management processes were ineffective in identifying the fatigue impairment experienced by the driver. [Safety issue]
• The guard did not take action, either to stop the train or warn the driver, when the driver started driving in the wrong running direction.

Other factors that increased risk

• The driver did not assimilate information from the guard, who told him, on two occasions, that he was in the wrong end for the instructed direction of travel.

Other findings

• The NCO recognised that train 165-S had started moving in the wrong running direction. The timely action by the NCO in stopping both trains (165-S and CA63) was fortunate.

Safety analysis

Introduction

The driver of passenger train 165-S drove the train in the wrong direction for 761 m. Previously the guard had warned the driver that he was in the wrong cab if he was going to St Marys. The guard did not take any action when the driver started driving in the wrong running direction. An NCO quickly realised the train was heading in the wrong running direction and contacted the driver to stop 165-S.

The driver did not realise the direction that the train was facing before moving the train. This was despite being familiar with the station, the route that he was to operate over, and the guard reminding him that he was at the wrong end of the train. A combination of changing ends a number of times, the length of time at the station, a high workload, and fatigue are the likely reasons he lost awareness of which way he was facing. The driver also felt under pressure to get the train moving after several telephone conversations with NCOs.

This section examines the contributing factors that led to the driver’s action including his work schedule and some preconditions for his unsafe act. It also explores the role of the guard and Sydney Trains fatigue management system.

Factors affecting the actions of the train crew

Time of day

The period between 0200 and 0600 is well established as a period of reduced performance. This is due to the effects of the circadian cycle, which predisposes humans to sleep during the night and be wakeful during the day. When we reverse these activities and work through the night and sleep during the day, we compromise the quality and the quantity of sleep, as well as the quality of the work performed. Thus, time of day creates an additional element of fatigue risk in 24−hour rail operations. The increase in fatigue and the deterioration in performance with time on task have been shown to occur more rapidly overnight.^[4]

Another factor that affected the driver’s performance was the night environment. Although there was adequate lighting around the platform and train, the darkness limited visual cues about the direction he was facing. The signal that was closest to the driver was facing the other way. It was designed for trains travelling in the Down direction on the Down Suburban line. The driver said he could not see or did not notice this signal.

Fatigue impairment

In the context of human performance, fatigue is a physical and psychological condition primarily caused by prolonged wakefulness and/or insufficient or disturbed sleep.^[5] The National Transport Commission recognises five main factors contributing to fatigue impaired work performance:

• the duration of a duty period (time on task), and the rest breaks within and between shifts
• inadequate sleep (or sleep debt), which results from inadequate duration and quality of prior sleeps
• circadian effects, which involve working and sleeping against natural body rhythms that normally program people to sleep at night and be awake and work during the day
• the type or nature of the task being undertaken (workload)
• the work environment.

These factors are compounded by a person’s body clock, environmental conditions, stress, age and personal health and fitness.^[6] Fatigue can have a range of influences on performance, such as decreased short-term memory, slowed reaction time, decreased work efficiency, reduced motivational drive, increased variability in work performance, and increased errors of omission.^[7] Transport accident investigation agencies have identified fatigue impairment as a causal factor in many accidents and incidents.

The driver indicated during an interview that at the start of the shift he felt exhausted, then while he was working on the train ‘adrenaline kicked in’. However, as the shift progressed, he got tired. He said that at the time of the incident he ‘felt drowned - exhausted in the cab'. As an explanation for why this incident happened, he said it was ‘particularly to do with so many hours without sleep’. It should be noted that the driver had a personal responsibility to declare himself unfit for work if he felt that his performance would be affected by fatigue. Research has shown that assessing your own level of fatigue is difficult.^[8] There are also a number of reasons why train crew are reluctant to decline an extra shift. Although not indicated by the crew in this incident, common reasons cited by train crew for accepting shifts when fatigued include the loss of income and gaining a reputation as someone who is not reliable.

The scheduling of drivers to work in the early hours of the morning is unavoidable. Knowing the risks associated with early morning shifts is important to optimise the rostering of train crew. The selection of this driver to work this shift increased his risk of error.

Given the driver’s actions and his reported state of fatigue impairment, as well as the established links between fatigue impairment and increased error, Sydney Trains’ management of fatigue risk was investigated.

Driver’s roster

An examination of the driver’s roster, including the incident shift, showed that he had worked 12 of the previous 14 days. In addition, this shift, a stand-by shift, was his tenth consecutive shift. The previous shifts all started in mid-afternoon or in the evening. He worked no morning shifts. This meant he was in a pattern of going to bed around 0100 and sleeping in. He said that if he had not worked this shift he would have gone to bed about midnight. The incident occurred at 0513, a time when he had planned to be sleeping.

The driver said that he started the day about 0800 and spent the day visiting friends. Rostered as a stand-by driver he received a call from train crewing at 2022.

Some of the rostering principles set down by Sydney Trains are:

• maximum shift length is set as 9 hours for the driver of a suburban train
• workers new to shift work or returning should not be rostered on night work or early morning for their first shift
• total hours worked should be no more than 48 hours per week
• break of 11 hours between shifts
• maximum number of shifts is 12 in a 14 day period
• limit night shifts and early morning starts
• schedule frequent breaks during a night shift or if the work involves sustained mental or physical activity.

Although the driver considered that he was affected by fatigue when the incident occurred, Sydney Trains use of bio-mathematical modelling did not predict that the driver’s roster would place him at risk. Their assessment of the suitability of the roster for managing fatigue risk was based primarily on the use of a bio-mathematical fatigue modelling program known as the Fatigue Audit Interdyne (FAID).

Bio-mathematical models attempt to predict the effects of different working patterns on subsequent job performance, with regard to the scientific relationships between work hours, sleep, and performance.^[9] FAID does not predict fatigue but rather predicts a sleep opportunity, demonstrating only that the organisation has provided employees with an adequate opportunity to sleep, producing a work-related fatigue score.^[10]

When evaluating rosters, there are a number of documented limitations with over-reliance on bio-mathematical models such as FAID. Because the distribution of fatigue across a given population of employees working the same roster is significant, it is difficult to generalise from the average data generated by a bio-mathematical model. As noted by the NSW Independent Transport Safety Regulator (ITSR):

…fatigue models are appropriate to use as one tool to help evaluate group rosters to help identify how aspects of fatigue exposure are distributed. Model outputs... should never be the sole basis for a safety risk management decision regarding work hours.^[11]

FAID, along with other bio-mathematical models, is a useful tool to account for hours of sleep opportunity provided, thereby providing an indication of fatigue exposure across a group of employees. It cannot account for the hours of sleep actually achieved by individuals, nor for the quality of that sleep. These additional factors necessitate the use of multiple layers of controls to manage fatigue-related risk.

Sydney Trains’ management system included policies, procedures, and training to address train crew fatigue impairment. These systems provide guidance for management and employees to ensure there is an awareness of countermeasures in this area. This case should serve as an opportunity to review the rostering of train crew, especially those called in on the stand-by roster.

Time pressure

For most transport operators there is a balance between on-time running and having a safe system. ‘To achieve both safety and on-time running requires the ability to identify hazards that can disrupt services or compromise safety and efficiently manage the risks those hazards create’.^[12]

Both train crew received a number of calls from NCOs throughout the shift. The train was expected to be moved once power was restored to the electrical supply. It is likely that NCOs were concerned about delays to the upcoming morning peak. This concern was communicated to both the guard and the driver.

The conversation between the NCO and the driver two minutes before he eventually moved the train was as follows:

The driver said later, 'I felt under pressure to get moving from the box. I moved a few seconds after talking to the (signal) box’.

Communication was hampered by the train radio not working. Initially, this meant information to the driver was relayed via the guard and station staff. Eventually communication was made directly to the driver via his mobile phone. Normally drivers must turn off their mobile phones when driving, but an exception is made when the train radio is not working.

Area control also contacted the guard. The guard was told, correctly, that the train could be moved without a working train radio. The NCO asked that the driver be reminded that a document about this had been released the previous week.^[13] The guard was also told that, ‘it’s getting critical that we need him to move’.

Research suggests that a call from a controller to explain a delay increases pressure on the driver to perform.^[14] ‘In general, under stress, attention appears to channel or tunnel, reducing focus on peripheral information and tasks and centralising focus on main tasks’.^[15] The tunnelling of attention can be a good thing or a bad thing for performance. In this case, the driver said he was completely focussed on the controls in front of him. It is likely that this contributed to him confusing the direction in which he was about to move.

Workload

The driver experienced a period of sustained high workload during his time at Mt Druitt station in the hours leading up to the incident. For over three hours, he made or received a large number of phone calls communicating with network control, train maintenance and the guard. He was on his feet during this time, either standing in the train cab, walking to the other end of the platform or walking up to the concourse.

Research has shown that a high workload can result in slower task performance and errors. ‘Unusual or high workload situations and situations where people are under time pressure can contribute to fatigue related incidents. Rather than causing fatigue in the traditional sense, workload has been described as a factor which can either mask or augment the effects of fatigue. People working under time pressure, or with a high workload, are most likely to make errors at the time of day that this incident occurred.’ ^[16]

Time at station

The amount of time the driver spent at the station before starting to drive may have affected his performance. The driver had been at Mt Druitt station since 0154 and, for the majority of the time, working and problem-solving to get the train started. For three hours, his focus of attention was directed at fixing problems with the train. The driver’s attention was away from the routine task of driving. When he departed, it was likely his mind was still engaged with the previous task he had spent so much time working on.

The driver said at interview that, after eventually moving the train, ‘when I put my head up, something was weird in my brain. I saw we were not on the right path, with 10 years’ experience as a driver. So everything it was upside down’.

Research suggests that an extended time spent at the station serves to dislocate the driver’s attention from the primary task and safe working. This research found that inattentiveness was deemed to arise primarily from the consequence of disengagement from an active driving state, which gives rise to the process of distraction and reduced situation awareness.^[17]

Multiple end changes

Since arriving at Mt Druitt station at 0154, the driver had changed ends seven times. On another occasion, he walked half way along the platform and returned. He had also left the train and walked up to the concourse on two occasions. The timing of driver movements is shown in the table below:

It is likely that changing ends on multiple occasions confused the driver. After the train technician arrived, the driver and train technician changed ends twice together (0403 and 0502) and the driver may have thought he would be returning to the country end. He said he thought the train technician would be travelling to St Marys with him. After the train technician left the driver in the cab, the driver should have returned to the country end. Instead the driver prepared to move the train, exchanged bell signals with the guard, received a phone call from the signal box and an intercom call from the guard, then moved the train shortly afterwards.

The role of the guard

The use of a driver and guard is an important measure to mitigate the risk of driver error. ‘Train Crew are responsible for the safety of all passengers on the train, and must be prepared to stop a train immediately if an emergency situation arises. The Train Crew must assist each other to provide for the safety of all passengers’.^[18]

A guard provides a level of redundancy in the system. It is essential that guards are not reluctant to take action in an emergency.

The guard was less experienced than the driver. They had not previously worked together. The guard reminded him at least twice that he was in the wrong end of the train if they were going to travel to St Marys. The driver recalled that the guard had told him this. It seems that the driver did not assimilate the significance of the advice, given all that was going on at the time.

The guard took no action when the train started moving in the wrong running direction. This was despite knowing the train was going the wrong way. The guard thought that the driver might have received authority to do this. After the incident, the guard contacted the Rail Management Centre to ask them if they had given authority from the driver to go in the wrong running direction, perhaps being issued a Special Proceed Authority. The guard was told that they had not given any such authority to the driver.

If the guard thought the train was going in the wrong running direction a number of actions could have been taken. These included:

• calling the driver and asking him what he was doing
• giving a bell signal, of two bells, which tells the driver to stop immediately
• operate the emergency brake isolating cock to bring the train to a stand.

Instead, the guard made a decision to watch for passengers on the platform that may have been trying to board the train before it moved off. There were few passengers on the station at the time.

Since the late 1970s, aviation accident investigation agencies have identified ‘authority gradients’ existing between crew contributing to incidents. One significant aviation accident where an authority gradient was a contributing factor was the collision of two Boeing 747s at Tenerife Airport, in 1977. The crash killed 583 people, making it the deadliest accident in aviation history.

‘In a study of 249 airline pilots in the United Kingdom, nearly 40 percent of first officers stated that they failed to communicate safety concerns to their captains on more than one occasion for reasons that included a desire to avoid conflict and in deference to the captain’s experience and authority’.^[19]

In 2003, a passenger train derailed at Waterfall, NSW killing 7 persons including the driver. The Special Commission of Inquiry set up to investigate this accident found that an authority gradient existed between the guard and driver. This was one of the factors that discouraged the guard from responding in the emergency. One recommendation discussed improving driver and guard training to encourage teamwork and discourage authority gradients.^[20]

Both driver and guard from the Mt Druitt incident had received training about effective communication and teamwork, the guard most recently in 2013.

Track configuration

The track configuration between Westmead and St Marys is different to many other areas in the Sydney metropolitan network. In most multiple track areas, the sequence of tracks will generally be an Up line next to a Down line. The track configuration at Mt Druitt placed both Down lines next to each other, and both Up lines next to each other. This has caused confusion to some drivers and maintenance staff in the past. There is no evidence that this contributed to the driver moving the train in the wrong direction.

__________

4. Williamson, A., Lombardi, D.A., Folkard, S., Stutts, J., Courtney, T.K. & Connor, J.L. (2011). The link between fatigue and safety. Accident Analysis and Prevention, 43, pp. 498-515.
5. National Transport Commission (2008). National Rail Safety Guideline. Management of Fatigue in Rail Safety Workers. p.5.
6. Ibid.
7. Battelle Memorial Institute (1998). An Overview of the scientific literature concerning fatigue, sleep, and the circadian cycle. Report prepared for the Office of the Chief Scientific and Technical Advisor for Human Factors, United States Federal Aviation Administration.
8. Van Dongen, H.P.A., Maislin, G., Mulligan, J.M., Dinges, D.F. (2003). The cumulative cost of additional wakefulness: Dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep. Vol. 26. pp.117-126.
9. Dawson, D., Noy, Y.I., Harma, M., Akerstedt, T. & Belenky, G. (2011). Modelling fatigue and the use of fatigue models in work settings. Accident Analysis and Prevention, 43, p. 551.
10. Ibid., p. 553.
11. Independent Transport Safety Regulator (2010). Transport Safety Alert 34 - Use of bio-mathematical models in managing risks of human fatigue in the workplace.
12. McInerney, P.A. (2005) Final Report of the Special Commission of Inquiry into the Waterfall Rail Accident Vol. 1 p. xviii
13. Sydney Trains. (2015) Defective Train Radios. General Instruction – Operations Directorate 23/2015.
14. Naweed, A. (2013). Psychological factors for driver distraction and inattention in the Australian and New Zealand rail industry. Accident Analysis and Prevention, 60, pp.193-204.
15. Staal, M. A. (2004) Stress cognition and human performance – A literature review and conceptual framework. NASA Technical Memorandum. NASA/TM—2004–212824. p.31.
16. National Transport Commission (2008). National Rail Safety Guideline. Management of Fatigue in Rail Safety Workers. p.5 -8.
17. Naweed, A. (2013) Op. Cit. p.199.
18. RailCorp. (2013) TWP 100 Responsibilities of Train Crew. TOM Notice No. 16.
19. National Transportation Safety Board. (2011) Safety Recommendation A-11-39. p.3.
20. McInerney, P.A. (2005) Final Report of the Special Commission of Inquiry into the Waterfall Rail Accident Vol. 1 p. 339.

Safety issues and actions

Depending on the level of risk of the safety issue, the extent of corrective action taken by the relevant organisation, or the desirability of directing a broad safety message to the rail industry, the ATSB may issue safety recommendations or safety advisory notices as part of the final report.

Fatigue management

Sydney Trains' fatigue management processes were ineffective in identifying the fatigue impairment experienced by the driver.

ATSB Safety Issue No: RO-2015-005-SI-01

ATSB Recommendation No: RO-2015-005-SR-04

Sources and submissions

Sources of information

The sources of information during the investigation included:

• Downer Rail
• Sydney Trains

References

Battelle Memorial Institute (1998). An Overview of the scientific literature concerning fatigue, sleep, and the circadian cycle. Report prepared for the Office of the Chief Scientific and Technical Advisor for Human Factors, United States Federal Aviation Administration.

Dawson, D., Noy, Y.I., Harma, M., Akerstedt, T. & Belenky, G. (2011). Modelling fatigue and the use of fatigue models in work settings. Accident Analysis and Prevention, 43, pp 549-564.

Independent Transport Safety Regulator (2010). Transport Safety Alert 34 - Use of bio-mathematical models in managing risks of human fatigue in the workplace.

McInerney, P.A. (2005). Final Report of the Special Commission of Inquiry into the Waterfall Rail Accident Vol. 1.

National Transport Commission (2008). Management of Fatigue in Rail Safety Workers. National Rail Safety Guideline.

National Transportation Safety Board. (2011). Safety Recommendation A-11-39.

Naweed, A. (2013). Psychological factors for driver distraction and inattention in the Australian and New Zealand rail industry. Accident Analysis and Prevention, 60.

RailCorp. (2013). TWP 100 Responsibilities of Train Crew. TOM Notice No. 16.

Staal, M. A. (2004). Stress cognition and human performance – A literature review and conceptual framework. NASA Technical Memorandum. NASA/TM—2004–212824.

Sydney Trains – RailSafe website. (2015). <https://railsafe.org.au/glossary&gt;

Van Dongen, H.P.A., Maislin, G., Mulligan, J.M., Dinges, D.F. (2003). The cumulative cost of additional wakefulness: Dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep, 26, pp117-126.

Williamson, A., Lombardi, D.A., Folkard, S., Stutts, J., Courtney, T.K. & Connor, J.L. (2011). The link between fatigue and safety. Accident Analysis and Prevention, 43, pp 498-515.

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:

• Downer Rail
• the Downer Rail train technician
• Office of the National Rail Safety Regulator
• Pacific National
• Sydney Trains
• the train crew of 165-S

Submissions were received from Downer Rail, the Office of National Rail Safety Regulator, Pacific National, Sydney Trains, and the train crew of 165-S.

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

The occurrence

Events prior to the occurrence

On Wednesday 11 March 2015, at about 1840,^[2] a storm blew a house roof off and into the rail corridor. The roof landed on the tracks at Mt Druitt, which affected the overhead electrical supply. Consequently, the track between Blacktown and Penrith was partially closed and Sydney Trains passenger train, 165-S, was held at Mt Druitt station. Passengers disembarked and continued their journey by other means.

Sydney Trains’ Train Crew Assignment Centre (TCAC) decided that the existing train crew would need to be relieved if the train was going to be held at Mt Druitt station for an extended time. TCAC called a driver and guard who were on a stand-by roster and offered them the extra shift. Both accepted and made their way to Central station. The guard signed on at 2000 and the driver at 2100.

Before going to Mt Druitt, the driver and guard completed a passenger service from Central to Hornsby. After this trip they were directed to Mt Druitt station to relieve the train crew on 165-S.

They travelled separately to Mt Druitt station. The guard arrived at 0128 and the driver at 0154. Both went to the country end of platform 3 where the previous train crew were waiting to be relieved. The driver received handover information about problems with the train from the previous driver. He was advised that:

• the overhead electrical supply was off
• the internal cab lights were not working
• the external lights were flashing on and off
• the pantographs were down and the pantograph pump was not responding
• the Metronet train radio was not working
• the faults had been reported to mechanical control.

The previous driver left the station and, at 0205, the driver unsuccessfully attempted to log into the train’s control system and turn on the internal cab lights. The guard was also unsuccessful in attempting to log in to the system.

As the train radio was not working, the guard and driver exchanged mobile phone numbers to enable communication between them. A network control officer (NCO) reported after the incident that he was unable to establish effective communication with the driver until he obtained the driver’s mobile number around 0500. Meanwhile, much of the communication from the signal box throughout the night was via the guard’s mobile phone or via the Mt Druitt station staff, who would walk down to the platform and speak to the driver.

At 0216, the driver walked to the train’s cab at the city end in an attempt to log into the train’s control system. He was again unable to do so. He phoned the guard and requested that they change ends. He returned to the country end at 0218, passing the guard on the platform who went to the city end of the train.

At 0257, overhead power was restored to all running lines. At 0311, a member of Mt Druitt station staff walked down onto the platform and told the driver that the signal box was trying to contact him. The driver phoned the NCO, who informed the driver that power was restored and that he should get ready to depart.

The driver again attempted to log into the train’s computer system, but was unable to do so. The driver phoned mechanical control about logging in and they gave him further instructions to try to rectify the fault. The driver’s login attempts were again unsuccessful. He was then advised to go to the cab at the city end and try to log in there.

At 0332, the driver walked from the country end to the city end and found the guard on the phone to mechanical control discussing the train’s computer system. They both tried to log in. Their attempts were unsuccessful. The driver made his way back to the country end of the train to try a similar process, but was again unsuccessful.

At 0349, the driver left the country end of the train and walked along the platform while speaking to mechanical control on his phone. Halfway along the platform he turned back and returned to the cab at the country end of the train.

A few minutes later, the driver walked from the country end towards the city end. Mechanical control sent a train technician to assist the driver. He arrived at 0352 and met the driver on the platform. Both the train technician and the driver then walked along the platform to the city end of the train where they attempted to get the train working. The train technician requested the driver assist him with the procedure. Once again, the attempt was unsuccessful.

At 0403, the driver and train technician changed from the city to the country end of the train. Both the driver and train technician worked on restarting the train. After a few attempts, they were successful in raising the pantographs. Other issues, such as the train radio, needed attention by the train technician. The train technician left the train at 0436 to get his laptop from the work van. The technician returned to the country end and was successful in restarting the train’s computer. This restored the destination indication panel on the train, but did not fix the train radio problem.

The driver left the train again to go up to the concourse level to the toilet. The driver was on the phone the entire time until returning to the train. At 0452, the guard received a call from the Rail Management Centre discussing problems with the train and asking to inform the driver to move the train soon. The guard spoke to the driver about this message. At 0453, a member of Mt Druitt station staff walked to the country end of the train and passed a message to the driver that the signal box was trying to contact him.

At 0455, an NCO spoke to the driver on his mobile phone and asked the driver if everything was good and if he was ready to go. The driver told the NCO about the problems with the train radio. Just as the driver was asking about his instructions and where he was going, the NCO ended the call to take another call. He then called back at 0458. During this call, he told the driver to operate the train to St Marys, terminate the train, and then return to Macdonaldtown Stabling Yard. The driver stated, ‘OK, I understand’.

The driver called the guard at 0502 and asked to change ends with him. The driver and train technician then walked together towards the city end of the train. At the same time, the guard walked towards the country end. The three met in the middle of the platform and talked for a few seconds. The guard assumed that they were changing ends not to move the train, but to rectify more problems. After a short conversation between the guard and the train technician, the driver and train technician continued to the city end of the train. This was the final change of ends before the driver moved the train.

The driver had changed ends seven times in 3 hours.

The guard was informed that the train could run without a functioning train radio - the NCO said, ‘it’s getting critical, we need him to move’. At 0505, an NCO called the driver and asked if the driver still had a problem. The driver said that they were about to conduct a continuity test after which they would be ready to depart. The NCO said to the driver, ‘(we are) trying to get you motivated, that’s all’.

The occurrence

The train technician, having completed his work, left the driver at the city end of the train at 0507 and departed the station. At 0511, an NCO called the driver and asked when he would be departing. The driver responded that they were departing ‘just now, just now’ but said he would talk with the guard first and probably depart ‘in five seconds’. Meanwhile, the guard called the driver on the train’s intercom system.

The guard informed the driver that he was in the wrong cab if they were heading to St Marys. The driver acknowledged that he heard this information. The driver and guard then discussed the continuity test before exchanging bell signals at 0512. The internal bell signals are used for communication between the driver and the guard. A single bell (all right) was given by the driver at 05:12:46; the guard returned this at 5:12:51.

Immediately after finishing the conversation with the guard, the driver engaged the power handle to 68% to move the train. The time was 0513:05. The train moved away from Mt Druitt station in the up running direction on the Down Suburban line^[3] (Figure 1). The train was travelling in the wrong running direction. The driver said he had his head down and was focussed on the controls. The guard was at the door of the train as it moved away from the station. The guard said that the reason the focus was towards the platform was in case late running passengers attempted to get onto the train.

Figure 1: Night time view from Platform 3 (city end)

The white arrow shows the wrong running direction that train 165-S travelled on the Down Suburban line.

Source: Sydney Trains

At 0513:30, after the train had travelled 111 m, the driver adjusted the power handle to 49%, a normal setting for the train to coast. At the same time, NCOs were observing the train movements on their Train Visibility System screen. They observed that the train was heading in the wrong running direction. An NCO made a call to the driver via his mobile phone at 0514:38 and told him to stop the train immediately and not move it any further. The driver said that he would do so and applied the brakes immediately.

At the same time a freight train, CA63, about 4 km away was travelling on the same Down Suburban line towards 165-S. It had just passed through Blacktown station and was approaching Doonside. An NCO contacted the crew of the freight train and told them to stop. This train was stopped before Doonside station.

Before the freight train was stopped, it was travelling in the correct running direction with line-side signals providing the driver with indications along the route. It is likely the driver of the freight train would have reached a signal at stop before reaching the passenger train. This was because the presence of the passenger train would have been detected by the signalling system, setting the signals to stop between it and the freight train.

Meanwhile, the driver of the passenger train had no signals facing him and no mechanism warning him of the freight train ahead. The available defences were the awareness of the driver and guard on the train, and the vigilance of the NCOs watching the Train Visibility System screen in the signal box.

Post-occurrence events

The time was 0514:46 when 165-S came to a stand with the leading car (city end) located at 42.470 km. It had travelled 761 m since leaving the station. During the trip, the train had reached a maximum speed of 33 km/h.

At 0515, the guard made a call to the signal box and enquired whether the driver had authority to head in the wrong running direction. The guard was told that the driver did not have this authority. The NCO again phoned the driver and instructed him to hold the train until an Incident Rail Commander arrived.

At 0521, the Rail Management Centre Shift Manager instructed an Incident Rail Commander to attend. He arrived at 0545 and tested both train crew for the presence of alcohol. Both returned a negative result. The driver was requested to change ends and drive the train back to Mt Druitt station. Authority was given and, at 0614, the train departed, arriving at Mt Druitt station a few minutes later. Both crew were drug tested at 0633. These results were also negative.

__________

2. The 24-hour clock is used in this report. Local time was Australian Eastern Daylight-saving Time.
3. Down lines typically carry train movements away from Sydney, Up lines towards Sydney.

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

On the morning of 28 February 2015, an instructor and student were conducting a training flight in a Robinson R22, registered VH-CMK, at Archerfield Airport, Queensland. The objective of the flight was to teach the student how to manage jammed anti-torque pedal^[1] and jammed collective^[2] emergencies. Conditions were fine and clear with a light and variable wind.

The flight commenced with the instructor flying the helicopter in a set direction, demonstrating how to effectively control the helicopter with the pedals jammed in position. The jammed pedal condition was simulated by holding the pedals in a set position with foot pressure, then manipulating the other flight controls and adjusting engine power and airspeed to control the helicopter. Satisfied that the key elements of the demonstration had been effectively addressed and nearing the boundary of the area in which the helicopter had been cleared to operate, the instructor turned the helicopter through about 180 degrees and commenced a similar demonstration travelling in the opposite direction.

During the second demonstration, the helicopter was established in forward flight around 15 ft above the ground at an airspeed of about 40 kt. The instructor simulated a jammed pedal condition, setting the left pedal slightly forward of the neutral position. As the demonstration progressed, the instructor elected to complete the exercise by conducting a simulated jammed pedal run-on^[3] landing. The helicopter touched down on a grass surface near the northern boundary of the airport, just outside the runway strips associated with runways 22R/04L and 22L/04R. The grass in the area where the helicopter touched down was slightly longer than the grass on the runway strips, but the instructor was comfortable continuing with the run-on landing, noting that it was not uncommon to operate helicopters on that surface.

The demonstration went as expected up until the point that the helicopter touched down. Still travelling forward at about 10 to 15 kt, the helicopter bounced slightly and yawed to the left. The instructor discontinued the demonstration at that moment, allowing himself full use of the pedals, but he was unable to correct the yaw before the helicopter touched down again. When the helicopter touched down a second time after a very short and shallow bounce, even though the helicopter was level, the forward part of the right skid dug into a surface undulation. The right skid then effectively acted as a pivot, tipping the helicopter to the right. The instructor fully lowered the collective, but the roll continued. The instructor then applied left cyclic^[4] but he was unable to stop the helicopter rolling onto its right side.

Aware that a fuel leak had developed, the instructor closed the fuel shut-off valve and turned the master electrical switch off. The instructor and student moved to a safe distance following which the instructor contacted air traffic control (who alerted emergency services). The instructor and student suffered minor injuries and the helicopter was substantially damaged.

Instructor comment

The instructor made the following comments in relation to the accident:

• The nature of the surface (outside the runway strips) probably contributed to the accident, given the manner in which the right skid dug into a surface undulation. There was a current NOTAM^[5] at the time of the accident stating that grass areas were soft and wet, but the reason the skid dug in rather than skipped forward, seemed to relate more directly to the slightly undulating nature of the surface, rather than how firm the surface was. During future similar exercises involving run-on landings on unprepared surfaces, the instructor intends to inspect the surface for suitability beforehand.
• The instructor was mindful of the possibility of dynamic rollover^[6] under the circumstances, so consciously avoided applying power and collective as the helicopter tipped.
• The instructor had invited the student to place his hands and feet lightly on the controls during the demonstration, to maximise the training benefit of the exercise. The instructor commented that the student may have inadvertently applied some pressure on the pedals during the accident, which could have reduced the effectiveness of the instructor’s attempt to correct the yaw after the initial bounce.

Safety message

This accident highlights the manner in which some hazards may not be immediately obvious. Helicopter training organisations are encouraged to consider the quality of the landing area surface during hazard identification and risk assessment processes associated with training operations, particularly those that involve run-on landings.

Aviation Short Investigations Bulletin - Issue 41

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. The anti-torque pedals are used in a conventional helicopter to adjust the pitch of the tail rotor blades, thereby adjusting the tail rotor thrust which counters the torque effect of the main rotor and controls the helicopter in the yawing plane. Pedal pressure is varied in response to changing conditions such as power changes and airspeed, to maintain coordinated flight. A jammed pedal condition denies the pilot the ability to use the pedals to vary tail rotor thrust.
2. Collective is the primary helicopter flight control that simultaneously affects the pitch of all blades of the lifting rotor. Collective input is the main control for vertical velocity.
3. A run-on landing is a helicopter landing that is made with forward speed.
4. Cyclic is 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.
5. 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.
6. In brief, dynamic rollover is the occurrence of a rolling motion while part of the landing gear is acting as a pivot. If the helicopter exceeds a critical angle it will roll onto its side.

Preliminary report released 21 May 2015

The information contained in this Preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the ongoing investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this Preliminary report. As such, no analysis or findings are included in this report.

What happened

During the morning of 28 February 2015, Maersk Garonne was under Fremantle marine pilot guidance on entry to the Port of Fremantle, Western Australia. At 0441 the pilot ordered port helm to bring the ship around to enter the port Inner Harbour entrance channel. During the turning manoeuvre, attempts to delay the ship’s arrival at the entrance beacons led to the ship passing south of the channel. At 0448 the ship grounded to the south of channel beacons number 1 and number 2. The ship was refloated at 0824 and taken to anchor.

What the ATSB has found so far

Based on preliminary information provided to the ATSB, it was apparent that the ship’s bridge crew had not been directly and actively engaged with the pilotage as it progressed, and were broadly unaware of the pilotage plan. Procedures had not been enacted and actions not taken to ensure the full bridge resources available to the pilot and master were utilised.

Investigation direction

The investigation is ongoing and will focus on:

• pilotage procedures, planning and practices, information exchange and contingency planning for Fremantle pilotage
• the existence, relevance, understanding and implementation of procedures by the pilotage company, port and ship to reduce the risk of grounding
• bridge team dynamics, resource management and personnel engagement during pilotage
• the implementation and effectiveness of bridge resource management training.

On 27 February 2015, the pilot of a Fletcher FU-24 aircraft, registered VH-KXT (KXT), and the pilot of a Gippsland GA-200 aircraft, registered VH-AGZ (AGZ), were conducting aerial agricultural operations on a property 13 km south-west of Cootamundra, New South Wales.

The pilots were using two runways, one aligned in approximately the 01/19 direction, and the other 06/24. Both of the aircraft were taking off from runway 06, however AGZ was landing on runway 24, and KXT was landing on runway 19. With both aircraft taking a similar amount of time to spread their fertiliser load, they were in an alternating sequence at the landing area.

After completing spreading one area, the pilot of AGZ reloaded and departed to locate the next paddock to be spread. It took about 5 minutes to determine the boundaries and commence spreading. At about 1015 Eastern Daylight-saving Time, as KXT was on final approach for runway 19, the pilot looked for AGZ on approach to runway 24, but did not see the aircraft. At about the same time, AGZ was on approach to land on runway 24 and the pilot looked for KXT approaching or on the runway, but did not sight that aircraft.

As KXT landed, the pilot was momentarily distracted as he observed the loader truck near the fence. AGZ was in the landing roll on runway 24 when the pilot sighted KXT about 10 m from his right wing. KXT was then in the landing roll on runway 19 and the pilot returned his gaze from the loader to the front of the aircraft, just as the propeller collided with the right wingtip and then the tail of AGZ. 

Both aircraft sustained substantial damage and the pilots were not injured.

The pilot of KXT commented that this incident highlights the importance of a thorough briefing between pilots prior to commencing operations.

Aviation Short Investigations Bulletin - Issue 40

On 27 February 2015, the pilot of a Liberty XL-2 aircraft registered VH-CZT, conducted circuits at Moorabbin Airport, Victoria. At the completion of the first circuit, the pilot flared the aircraft to land on runway 17 Left (17L). The main landing gear contacted the runway and the aircraft bounced into the air. The pilot immediately applied full power and conducted a go-around.

The pilot then conducted a second circuit and established the aircraft on final approach to the runway about 3-4 kt slower than the previous approach. The aircraft touched down normally and the pilot then performed a touch-and-go and continued the circuit.

On the third approach to runway 17L, as the pilot flared the aircraft for the landing, it collided with the runway. The aircraft then bounced into the air and the pilot initiated a go-around by applying full power and slight forward pressure on the control stick. Instead of climbing away, the aircraft struck the runway again and veered to the left. The pilot applied right rudder in an attempt to counteract the left yaw and the aircraft again became airborne before colliding with the runway and skidding towards the grass to the left of the runway.

During the accident sequence, the main landing gear collapsed and the propeller and left wingtip struck the runway, resulting in substantial damage. The pilot was not injured.

This incident highlights how different aircraft types and configurations can affect the approach profile and landing characteristics. The visual cues and the control inputs required to conduct safe landings vary depending on many factors including aircraft design and performance, weight and balance, and environmental conditions including wind strength and direction.

Aviation Short Investigations Bulletin - Issue 40

What happened

On 20 February 2015, at about 1130 Western Standard Time (WST), a Diamond DA20 aircraft, registered VH-YNB (YNB), taxied at Jandakot Airport, Western Australia, for a flight to the training area south of the airport, with a trainee instructor and a flight instructor on board. The instructor was seated in the left seat and acting as a student pilot, with the trainee instructor in the right seat. The sequence to be practiced was climbing and descending, with emphasis on keeping a good lookout and maintaining awareness of other traffic at all times.

At about the same time, the pilot of a Mooney M20 aircraft, registered VH-SJT (SJT), taxied for a private flight to Busselton Airport with three passengers on board. The instructor of YNB observed the Mooney taxiing. During the taxi, the pilot of SJT demonstrated to the front seat passenger, how to close the aircraft door. The pilot then elected to leave the door open to improve comfort in the aircraft as it was a warm day, and planned to have the passenger close the door prior to take-off.

At about 1136, the aerodrome controller (ADC) cleared YNB for take-off from runway 24 Right (24R) and advised the pilot of helicopter traffic ahead, which the trainee instructor reported in sight. About 16 seconds later, the pilot of SJT reported ready at the holding point for runway 24R. The ADC cleared SJT for take-off about 23 seconds later, at 1137, and did not advise of any traffic. The pilot of SJT then commenced the take-off run and directed the front seat passenger to close the door. The front seat passenger was unable to fully close the door, resulting in air flowing in on the passengers seated in the back seat and articles being blown around inside the cabin. The pilot continued with the take-off and asked the passengers to stay calm and silent, and the door was left partially open. Both aircraft departed Jandakot via Yangebup Lake at about 1,000 ft (Figure 1).

Figure 1: Perth Visual Terminal Chart with relevant points overlaid

Source: Airservices Australia annotated by the ATSB

After passing Yangebup Lake, the trainee instructor of YNB switched the radio from Jandakot Tower to Perth Centre frequency and changed the transponder code from 3000 to 1200.^[1] The pilot of SJT did likewise, and when changing the transponder code, realised that he had departed with the transponder selected to ‘Standby’ rather than ‘Alt’. He observed a high-wing aircraft about 2 NM away in his 2 o’clock position^[2] and assumed it was the aircraft that had departed Jandakot ahead of him and assessed that his track to Lake Thomson would be well clear of that aircraft. He then turned onto a heading of 192° and established the aircraft in a climb to 1,500 ft.

When overhead Lake Thomson, the trainee instructor of YNB conducted a climb to 1,500 ft. At 1,500 ft, he lowered the aircraft nose and levelled off to check the area ahead was clear of traffic and both pilots scanned from right to left and did not see any aircraft. The instructor then observed SJT pass diagonally from behind and left to right about 20 ft above YNB. The trainee instructor sighted SJT as it appeared from overhead to pass YNB.

At about 1141, the instructor of YNB called the pilot of SJT on Perth Centre frequency and advised that SJT had just passed straight over the top of them. The pilot of SJT responded and looked behind but did not see YNB. He assumed that it was the pilot of the high-wing aircraft, some distance away, who had contacted him and did not believe there was any risk of collision. SJT continued to Busselton with the door partially open.

At about 1144, the instructor of YNB asked the Tower controller whether SJT had been given YNB as traffic and as the ADC had handed over to another controller, was told they would find out but did not subsequently provide a response.

Pilot comments

The pilot of SJT reported that in future he plans to absolutely identify the type, and maintain visual contact with, aircraft in the control zone. He had misidentified the aircraft he sighted and should have realised it was not the Diamond that had taken off in front of him. In future, he would close the door himself prior to commencing the take-off run. Despite the distraction from the passengers due to the open door, he maintained his focus on the take-off, initial climb and after take-off checks. The distraction may have resulted in his misidentifying the aircraft ahead.

Airservices Australia investigation

Airservices Australia conducted an internal investigation into the incident and found the following:

Both aircraft were operating under the visual flight rules (VFR) and the take-off clearance was issued to SJT about 60 seconds after the clearance was issued to YNB.

The Manual of Air Traffic Services (MATS) Version 30 section 9.1.5 Traffic Information, paragraph 9.1.5.1 stated that in Class D airspace VFR aircraft will be provided traffic information on other VFR aircraft. Section 9.1.6 Traffic information assessment and content, paragraph 9.1.6.2 stated to ‘Pass traffic information to qualifying aircraft when data assessment indicates the possibility of conflict’.

No traffic information was passed to SJT on the preceding departure of YNB. The controller assessed that based on the existing separation at departure and the expected speed differential of the aircraft, no possibility of conflict existed inside Class D airspace between YNB and SJT.

The information available suggested that the aircraft came into conflict 2 NM beyond the Jandakot control zone boundary. The absence of secondary surveillance radar data for SJT was consistent with the pilot report that their transponder remained in standby mode until approximately the time of the conflict with YNB. As both aircraft were then outside controlled airspace they were not subject to a separation service. Due to the absence of surveillance data for SJT, no opportunity existed for a controller to identify the conflict.

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.

Operator of VH-YNB

As a result of this occurrence, the operator of YNB has advised the ATSB that they have reminded all students and company pilots to remain vigilant in looking outside for other aircraft.

Safety message

This incident highlights the importance of being aware of other aircraft operating in the area, particularly around airport departure points. While operating in Class D airspace, pilots and air traffic control have a dual responsibility to maintain situational awareness of other traffic. When departing into Class G airspace it is important for pilots to continue their awareness of other aircraft and to keep a good lookout at all times.

Distractions such as an open door can adversely affect the safety of a flight. The ATSB research report Dangerous Distraction: An examination of accidents and incident involving pilot distraction in Australia between 1997 and 2004, stated that the most serious source of pilot distraction occurred as a result of an unexpected equipment malfunction.

Two similar incidents were investigated by the ATSB where an open door resulted in pilot distraction. The reports are available at the following links:

Aviation Short Investigations Bulletin - Issue 41

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.

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1. 3000 is the generic code used for civilian flights in class D airspace and 1200 is the code used for VFR flights in class G (or E) airspace.
2. The clock code is used to denote the direction of an aircraft or surface feature relative to the current heading of the observer’s aircraft, expressed in terms of position on an analogue clock face. Twelve o’clock is ahead while an aircraft observed abeam to the left would be said to be at 9 o’clock.

The Civil Aviation Safety Authority (CASA) released Airworthiness Directive AD/GEN/87 Primary Flight Control Cable Assembly Retirement in February 2015 which required the retirement of control cable assemblies after 15 years in service. Following the release of the AD, CASA received a service difficulty report where a cable terminal fitting exhibited cracking after less than 10 years in service. As the cable exhibited cracking prior to the retirement life stated in the AD, it was requested that the Australian Transport Safety Bureau (ATSB) examine the terminal to determine the mode of failure, and if it was the same mechanism as that described in the AD.

The submitted terminal exhibited four longitudinal cracks extending approximately 5mm from the end of the terminal. Small indentations were identified on either side of two of the cracks on opposite sides of the terminal. These were considered to be an artefact of the swaging process. The location and orientation of the cracking was different to those of the terminals examined previously as part of investigation AE-2012-028. There was no evidence of the highly branched cracking that was seen in other examples and which is normally associated with stress corrosion cracking.

The cracking on the submitted terminal likely initiated as a result of the mechanical damage that occurred during the manufacturing process. The terminal has been returned to CASA, who are continuing their investigations into the origin of the terminal and the mechanical damage.

Figure 1: Terminal submitted to the ATSB, crack location arrowed

Source: ATSB

Figure 2: Magnified view of terminal, showing the mechanical damage either side of the crack

Source: ATSB

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The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003.