Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the Australian Transport Safety Bureau (ATSB) to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.

On 24 October 2014, the ATSB commenced an investigation into a loss of separation assurance involving an Embraer EMB-135, registered VH-JTG, and an Airbus A321, registered VH-VWX, overhead Taroom Aerodrome, Queensland on 21 October 2014.

Examination of the information collected during the investigation indicated that the aircraft were assigned the same flight level on crossing tracks resulting in a loss of separation assurance. VH-JTG passed in front of VH-VWX and separation reduced to 6.6 NM (12 km). The lateral separation standard at the time was 5 NM (9 km) and there was no Short Term Conflict Alert (STCA) or other alert issued, including by the aircraft’s systems.

The ATSB did not identify any organisational or systemic issues that contributed to the incident and assessed that no safety issues would be identified through further investigation. On that basis, the ATSB has decided to discontinue its investigation.

Safety summary

What happened

On 23 October 2014, Genesee & Wyoming Australia (GWA) train 5DD2 departed from Kevin, a gypsum mine near Penong, South Australia. The train was loaded with gypsum destined for the port at Thevenard. Shortly after entering the Penong Junction to Thevenard section, the driver felt two severe jerks and noticed a loss of brake pipe pressure and an unusual amount of dust from the rear of the train. After the train was brought to a stop, the second driver walked back along the consist and found several derailed wagons and a section of damaged track.

What the ATSB found

The ATSB found that the track infrastructure was generally in poor condition, with the rail exhibiting substantial head wear. The poor track condition had also allowed a wide gauge condition to develop, allowing rolling stock wheels to track away from the rail web. As a result of the head wear, gauge widening and the wheel tracking position, the capacity of the rail to support the wheel loads had been progressively reduced. This condition ultimately resulted in the failure of the rail head during the passage of train 5DD2, with the consequent derailment and infrastructure damage.

It was evident from the ATSB’s investigation that defect monitoring and reporting was not being conducted as specified in the relevant Code of Practice. As such, awareness of the rail condition and deterioration was reduced and remedial maintenance actions were not being planned or implemented.

The ATSB also found that Genesee & Wyoming Australia’s maintenance oversight had been limited, allowing the track to deteriorate to a point where trains could not be run safely.

What's been done as a result

Following the derailment, the track maintainer (Transfield Services) has undertaken to increase track inspection detail, with a view to identifying areas of concern for assessment and remedial works. GWA advised that they undertook their own inspection of identified sections of track with an emphasis on gauge and cant, and identified other locations that presented potential for a derailment to occur under similar circumstances. This resulted in the application of temporary speed restrictions over the affected areas and the insertion of timber sleepers to maintain gauge.

GWA also advised that they will undertake a review of the processes and procedures applied to rail infrastructure maintenance and have requested more regular track inspection reports from the contracted infrastructure maintainer. The ATSB has been advised that upgrade works are scheduled to improve the track condition and reduce the associated derailment risk, with the majority of works to be completed in 2015.

Safety message

This incident illustrates the importance of rail maintainers effectively documenting and accurately reporting the condition of the track to the responsible owner/operator. Similarly, owners and operators must maintain diligent oversight of infrastructure maintenance activity, particularly in areas where the track condition is known to be poor or deteriorating.

Context

Location

Thevenard is located on the Eyre Peninsula in South Australia, near Ceduna. The rail line extends from Kevin, where a gypsum mine is located, through to Thevenard where the port handles bulk gypsum shipments.

The derailment occurred at the 431.225 km point between Penong Junction and Thevenard (Figure 2).

Figure 2: Map of the Penong – Thevenard track system

Source: South Australian Government, Department for Transport, Energy and Infrastructure, annotated by ATSB

Train and crew information

Train 5DD2 was a gypsum transport service that operated between Kevin and Thevenard. The train consisted of three locomotives (GWA 1601 leading, GWA 873 and GWA 850 trailing) hauling 55 ore hopper wagons of type ENH and ENHA. The train had an overall length of 424 m and a gross weight of 2,475 tonnes. The locomotives were equipped with Quantum event recorders; the information from which was downloaded by GWA and provided to the ATSB for use in the investigation.

ATSB analysis of the information from the train’s recorders indicated that there had been no handling issues experienced during the lead up to the derailment.

As part of the post-derailment investigation, the involved wagons’ wheel profiles were checked by the operator and found to be within serviceable limits.

Train crew

The train was crewed by two drivers; both were appropriately qualified, held the required route certifications and were assessed as fit for duty.

Following the derailment, the drivers underwent mandatory testing for prior drug and alcohol use, with negative results returned for both.

Track Information

History

The Thevenard to Kevin track was a single, narrow gauge^[3] railway line from the Port of Thevenard, through Ceduna to the Penong Junction and on to Kevin (Figure 2). The track consisted of a mixture of mechanically-jointed 63 lb/yd (31 kg/m) and 82 lb/yd (41 kg/m) rail, directly fastened to wooden sleepers. The track section where the derailment occurred was constructed in 1915, with the line from the Penong Junction to Kevin being laid in the 1960s. The line was originally operated by South Australian Railways until the mid-1970s, after which it was used by a number of operators. In 1997, a ground lease was granted to Australian Southern Railroad (now GWA). Information available to the ATSB indicated that the general condition of the line had been degrading significantly over a number of years; influenced primarily by limited infrastructure investment and maintenance activity.

The mine at Kevin had been owned and operated by Gypsum Resources Australia since 1984. Penong, located beyond Kevin, had grain storage and loading facilities, but this section of line was closed to rail traffic in 1997 due to minimal use and poor track condition. In a submission to Infrastructure Australia in 2008, the Eyre Regional Development Board identified that significant upgrading and capital investment was required to maintain the rail in an efficient operational state. The investment was not deemed economically justified, unless the gypsum mine could be guaranteed to have continued operations for a number of years.

In 2006, Transfield Services, under contract to GWA, became responsible for the ongoing maintenance and serviceability of the Thevenard to Kevin line. A capital upgrade program was initially proposed for 2013, but the works were further delayed as a commercial agreement with the mine (to ensure continued usage of the rail line) was not yet in place. In July 2014, an agreement was reached with the mine to justify the capital investment needed. A capital works program was then initiated, with a walk-through inspection identifying the scope of the project in August 2014, and capital works scheduled to begin in 2015.

Site observations

Examination of the rail in the area immediately prior to, and at the point of derailment (POD), indicated that the left hand side rail head (in the direction of travel) had fractured near the running face (Figure 3).

Figure 3: Fractured rail head

The track showed substantial rail head wear, with evidence of significant metal flow and corrugation (Figure 4). In addition, the wear pattern on the rail face indicated that wheel flanges had been tracking at least 20mm inboard from the rail running face, suggesting lateral (gauge-widening) movement of one or both rails through the POD.

Figure 4: Rail head wear, metal flow and corrugations

The combination of substantial head wear and the wheel tracking location increased the likelihood of rail head failure during the passage of a train. From the extent of wear and deformation of the rail head, the lateral movement of the track, and the inboard tracking position of the wheels, the ATSB concluded that the rail had been structurally unable to support the wheel loads, resulting in the vertical collapse and fracturing of the rail head during the passage of train 5DD2.

Given the extent of the rail head wear sustained, and that this type of damage develops progressively over time, it is very likely that the degradation would have been evident during any previous scheduled track inspections.

Inspection and maintenance

Track infrastructure deteriorates over time as a result of usage, age and other factors. It is the infrastructure manager’s role to implement a maintenance regime to ensure the track condition is periodically assessed and returned to an acceptable standard if defects are found. The process is based on a regime of inspection and maintenance aimed at ensuring that the infrastructure condition remains at or above defined limits that are appropriate for the operating requirements of the rail line. It is possible for trains to operate safely on infrastructure that is in a condition below defined limits, provided that appropriate measures are implemented to manage the associated risks.

In this case, the track inspection and maintenance standards were documented in the Westrail Narrow Gauge Mainline Code of Practice (CoP). The CoP specified the monitoring and maintenance requirements, including:

• the type of inspections and the frequency required
• the documentation requirements after track inspections
• acceptable wear limits, and
• maintenance requirements for detected defects.
• Considering the degraded condition of the Eyre Peninsula rail infrastructure, GWA had issued an addendum to the CoP (dated 1 April 2007), which provided for more frequent inspections, reduced maximum track speeds and modified maintenance defect limits.

Processes

In general, the track maintenance process required identification of track defects through routine inspection, followed by a planning phase to determine the work required and a Work Order being issued to conduct the remediation. To this end, Transfield Services maintained a track fault list; a consolidated list of defects detected during track inspections and the associated rectification work planned. Transfield used this consolidated list to schedule works, and it was the only documentation provided to GWA for their oversight of the state of the track.

Track gauge

Track gauge is the distance between the gauge faces of the two rails and is normally measured at a point 16 mm below the top of the rail head (Figure 5). In this case, the rail head was so worn and distorted that track gauge could not be effectively measured in this manner during post-derailment inspections. Considering the evident running position of the rail wheels however, (Figure 6), the track gauge had very likely exceeded the maximum limit documented in the CoP addendum.

Figure 5: Track gauge measurement point

Figure 6: Rail condition and running position of wheels

The condition of sleepers and fasteners is critical for maintaining track gauge. In this case, their condition would have been difficult to determine visually, due to extensive coverage by gypsum product (Figure 7). Post-derailment examination however, found that the sleepers were in a poor condition, with limited gauge-holding capacity at the point of derailment. While the period over which gauge widening and poor sleeper/fastener condition had developed was unable to be determined, the level of rail wear and sleeper condition suggested that the track had been operating in a degraded condition for some time.

Rail condition

The CoP required rail head wear to be periodically assessed against prescribed limits, with defects beyond those limits reported for remedial action. Documentation is required detailing the location and wear levels where top or combined wear to the head profile exceeds 20% and side wear is greater than 15%. Where the prescribed wear limits are exceeded, a rating of the rail may be carried out using procedures detailed in the CoP, taking into account local factors and any pre-existing speed restrictions.

Corrugation of the rail was also evident at the point of derailment – a defect which develops over time and can lead to failure of the rail if left untreated. It was evident that this condition had been present for some time and would likely have been visible during scheduled track inspections.

During the investigation, the ATSB was unable to identify any documented evidence that the level of rail head wear or corrugation in the area of the derailment was being monitored, or that the severity of the condition/s had been reported to GWA for reassessment of operating limitations (load rating and speed restrictions).

Figure 7: Complete product coverage of sleepers and fasteners

Source: ATSB and ONRSR

Track inspection

The documentation suite in use for track inspection outlined the requirements for patrol, general and detailed inspections; all of which were used in conjunction with Transfield’s Technical Maintenance Plan to meet the CoP requirements. These documents detailed the procedures for completing the different types of inspections on various rail infrastructure elements, and contained inspection worksheets to record details of completed inspections and corrective work performed.

At the time of the derailment, the minimum (baseline) inspection requirements prescribed by the CoP addendum were for a scheduled track patrol to be conducted every 48 hours, a track geometry car to be run at a minimum of once a year, and on-rail ultrasonic testing required every 8 years.

While the CoP addendum procedures required 48-hourly inspections, there were no records available to confirm that those inspections had taken place between June 2014 and the derailment in October. Records were also unable to establish when the last track geometry car was run to detect and quantify any rail head defects. The track geometry car had the capability of detecting wide track gauge as well as the extent of the rail head wear.

Records provided to the investigation showed that the most recent ultrasonic testing was conducted in 2006, with no defects noted at the point of derailment at that time. The next ultrasonic test was due in 2014, however an earlier decision had been made, in light of the upgrade work proposed in 2013, to run that test during the early stages of the upgrade program.

Track maintenance

The risks presented by the deteriorating track infrastructure were able to be managed in accordance with the CoP and addendum, by applying operational restrictions and increasing the inspection frequency. The temporary speed restrictions in force at the point of derailment were applied in 2009, when Transfield Services was first contracted to provide track maintenance services.

The CoP indicated that speed restrictions, when used in conjunction with increased inspection frequency, were an appropriate risk control for some isolated defects until such time as the defects were rectified or a plan for a strategic upgrade was in place. While temporary speed restrictions can reduce the likelihood and consequences of an incident involving degraded track, they were not intended to be used as long term measures for ensuring the safety of the line.

At the time of the occurrence, other sections of the Eyre Peninsula rail infrastructure had been either closed due to the condition of the track, or had current speed restrictions, with the maximum line speed for a loaded train of 30 km/h. All of the speed restrictions current at the time of the derailment had been applied as a response to the state of the infrastructure.

Related occurrence

Derailment at Charra, November 2 2014

At about 1800 hours on 2 November 2014, train 1DD5 derailed at the 473.938 km mark between Kevin and the Penong junction. Subsequent investigation found a 200 mm section of broken rail associated with a mechanical joint. It was concluded that the broken section had separated during the passage of 1DD5 (Figure 8).

Figure 8: Rail defect in mechanical joint

Source: Transfield Services

While records of the inspections conducted after June 2014 were unavailable, the evidence of forced surface contact across the fractured web suggested the fracture within the mechanical joint had likely been present for a period longer than the time between inspections.

Investigations at the time found no records of routine inspections taking place at a frequency that would have detected the broken rail prior to the passage of the train. Similarly, there were no indications that a potential issue was being monitored and maintained appropriately, or had been reported to the rail operator.

__________

3. The track gauge of 1,067mm

Findings

From the evidence available, the following findings are made with respect to the derailment of train 5DD2 at Ceduna, South Australia, on 23 October 2014. 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 track infrastructure between Penong and Thevenard, SA had progressively degraded and was generally in poor condition.
• Substantial rail head wear and corrugation in the vicinity of the derailment, combined with a wide gauge condition and the consequent wheel tracking away from the rail web led to localised rail head failure and the derailment of train 5DD2.
• Track defect monitoring and reporting was not being conducted as specified in theWestrail Narrow Gauge Mainline Code of Practice, limiting the awareness of the deteriorating track condition and the need for reassessment of track operating limits. [Safety issue]
• The rail transport operator (GWA) had not maintained sufficient oversight of the activities of the rail infrastructure manager (Transfield Services), allowing the track to deteriorate to a level where trains could not be reliably run in a safe manner. [Safety Issue]

Safety analysis

On the basis of the evidence available from the incident site, it was concluded that the derailment of train 5DD2 resulted from the combined effects of a substantially worn rail head profile and wide track gauge. These conditions are characteristic of aging and deteriorating infrastructure. To properly manage a deteriorating asset, GWA, as the rail transport operator (RTO), was responsible for ensuring the standards being applied were appropriate for safe rail operations. This required an appropriate level of oversight of the contracted maintenance provider. As that provider, Transfield Services was required to periodically inspect, record and report the condition of the track to GWA, so that appropriate assessments and decisions could be made in managing the track condition.

Documentation and reporting

The ATSB found no evidence to indicate that regular (visual) defect monitoring and reporting was being conducted as specified in the CoP. As a result, remedial maintenance actions were not being planned or implemented. Records of routine inspections were not being kept, and accordingly, there was no information indicating the condition of the rail at the point of derailment. Without defects being recorded and entered into the maintenance scheduling system, no monitoring or maintenance actions were being implemented. Similarly, without the appropriate documentation and reporting, it was likely that GWA was not fully aware of the deteriorated state of the rail and the potential requirement for immediate maintenance actions.

In a similar manner, it was also evident that the track geometry inspection car was not being run at the required intervals. Use of the track geometry car may have identified any track alignment, wide gauge or rail head wear defects that required immediate action and which may not have been noted by visual (hi-rail) running inspections.

The track fault list examined by the ATSB did not include monitored defects, and had no entries between June 2014 and the incident – suggesting that known defects were not being monitored and new defects were not being identified and added to the list.

There was physical evidence to suggest that the defects which contributed to the derailment had been present for a significant period of time – further indicating that the inspection regime was not capturing defects or monitoring them appropriately. The nature of the track defects present at the derailment site (substantial rail head wear, wide gauge and corrugation) was such that they should have been identifiable during routine inspections, and consequently, should have been subject to a monitoring regime as defined within the CoP.

Oversight

The application of temporary speed restrictions in 2009, coupled with an increase in the inspection frequency of the track at the point of derailment suggested that from this time, there was at least a broad level of understanding around the deteriorated state of the track. The CoP indicated that speed restrictions and increased inspection frequency was an acceptable minimum response when applied to isolated defects, however it also indicated that a more comprehensive response may be necessary where multiple defects exist in a localised area. GWA had identified that a major upgrade was required to address the cumulative risks, but the implementation of this had been delayed due to ongoing commercial negotiations with the mine operator.

Whilst Transfield cited track occupancy authorities and daily work diaries as evidence that track inspections had occurred, there were no specific inspection records, nor were there any reports of defects found or maintenance action taken following these regular inspections. GWA had not required the routine provision of inspection records, with the only documentation received for oversight of the track condition being a consolidated track fault list provided quarterly. The track fault list contained no defects found or rectification work conducted as a result of routine inspections between June 2014 and the incident. The level of detail contained in the fault list was not sufficient to fully convey the deteriorated state of the track, and defects that required on-going monitoring were not included in the list. As such, GWA was likely not fully aware of the true state of the track infrastructure.

Where the rail was known to be in poor condition, GWA had not maintained sufficient oversight in managing the activities of the infrastructure maintainer. The limited information requested from, or provided by the contracted maintenance provider resulted in GWA being unable to effectively manage the deteriorating condition of the track. This led to the track remaining in operation while it deteriorated to a level below the limits documented in the CoP and addendum, and without having undergone a process of standards reassessment to ensure that ongoing rail operations remained safe.

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.

Where relevant, safety issues and actions will be updated on the ATSB website as information comes to hand. The initial public version of these safety issues and actions are in PDF on the ATSB website.

Maintenance, defect monitoring and reporting as per CoP

Track defect monitoring and reporting was not being conducted as specified in the Westrail Narrow Gauge Mainline Code of Practice, limiting the awareness of the deteriorating track condition and the need for reassessment of track operating limits.

Safety Issue number: RO-2014-018-SI-01

Oversight of Infrastructure Maintenance

The rail transport operator (GWA) had not maintained sufficient oversight of the activities of the rail infrastructure manager (Transfield Services), allowing the track to deteriorate to a level where trains could not be reliably run in a safe manner.

Safety Issue number: RO-2014-018-SI-02

Sources and submissions

Sources of information

The sources of information during the investigation included:

• Genesee & Wyoming Australia
• Transfield Services Ltd
• Office of the National Rail Safety Regulator

References

• Rail Industry Safety and Standards Board (2010), Glossary of Rail Terminology – Guideline. Available from: www.rissb.com.au
• AS 1085.1 - Railway track material—Steel rails—History (Supplement 1 to AS 1085.1—2002).
• Westrail Narrow Gauge Mainline Code of Practice Version Draft 1998
• Addendum to the Westnet Rail Narrow Gauge Mainline Code of Practice for the Eyre Peninsula Railroad

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 Genesee & Wyoming Australia, Transfield Services, the Office of the National Rail Safety Regulator (ONRSR) and the crew of train 5DD2.

Submissions were received from Genesee & Wyoming Australia and the Office of the National Rail Safety Regulator (ONRSR). The submissions were reviewed and where considered appropriate, the text of the report was amended accordingly.

The occurrence

At about 0230^[1] on 23 October 2014, the crew for Genesee & Wyoming Australia (GWA) train 5DD1 signed on for duty at Thevenard, South Australia. The train was scheduled to travel empty from Thevenard to the Gypsum Resources Australia mine at Kevin (Figure 1), to be loaded with gypsum before returning to Thevenard.

Figure 1: Derailment location map - South Australia

Source: NatMap Railways of Australia annotated by ATSB

At about 0300, the empty train departed Thevenard for the mine, arriving at 0507. After the completion of loading, the train departed the mine at 0636 as train 5DD2.

The Kevin to Thevenard track section had speed restrictions for loaded locomotives; varying from 20km/h to 30km/h due to poor track condition and geometry. As 5DD2 approached Thevenard, the driver increased the train speed to the permitted limit of 30km/h. At about 0906, the driver felt two severe jerks, followed shortly after by a loss of brake pipe air pressure, and then noted an unusual amount of dust rising from the rear of the train. The train was brought to a stop near the 431 km mark^[2].

At 0908, the driver contacted train control to advise that the train may have derailed, while the second driver walked back along the train to assess the situation. At 0919 the crew confirmed their location with train control and advised that the rear 13 wagons had derailed.

As the train had derailed and stopped on the approach to the level crossing at Kloeden Street, it caused the level crossing equipment to ring continuously. Consequently, the police attended the site at about 0923.

There were no injuries caused by the derailment, but approximately 120 m of track and 13 wagons were damaged. The track was reinstated for use on 26 October 2014.

__________

1. The 24 hour clock is used in this report to describe the local time of day, Central Standard Time (CST)
2. Distances are track kilometres measured from Port Lincoln Railway Station.

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 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.

The pilot reported that the aircraft was departing empty from the Snake Creek Fish Farm after delivering a load of freight. The main fuel tanks were 3/4 full and the auxiliary tanks were full. 

After the aircraft speed had passed Vmca and the aircraft was becoming airborne, the right engine failed. The pilot closed the throttles, selected the right propeller to feather, landed the aircraft and commenced braking. He assessed that insufficient runway remained for a successful stop, so he initiated a ground loop to the left. Just before the aircraft stopped, the nose leg struck a mound of earth that had been hidden in the grass. This caused the nose gear leg to collapse, and both propellers were damaged.

No reason for the engine failure could be established. The grass on the airstrip was long. This may have resulted in lower acceleration performance than the pilot had anticipated.

The aircraft was engaged on a VFR pilot navigation training flight. One cadet pilot had flown the aircraft from Tamworth to Coolangatta via Coffs Harbour earlier in the day. A second cadet pilot was conducting the return leg to Tamworth, with a landing at Glen Innes, under the supervision of an instructor.

At about 80 feet after take-off from Glen Innes the instructor initiated a practice engine failure. The aircraft was about 10 knots below the glide speed for the flap setting in use at this point. The cadet pilot promptly lowered the nose, but not sufficiently to obtain the desired glide speed or maintain the take-off speed. The instructor pushed the controls forward to lower the nose to the attitude normally required to maintain a safe speed. The flap setting was not altered to a landing position. Shortly after this the instructor realised that a high sink rate had developed and took corrective action to reduce the sink rate, including the application of power. The sink rate could not be arrested in the distance available and the aircraft landed very heavily.

Both main landing gears were damaged, and the right wing was rotated nose down. The aircraft came to rest on the runway, after a ground run of 100 metres. The cadet pilot suffered a cut above his left eye when his head struck the transmit switch on the control yoke during the landing impact.

The company's operations manual for the aircraft type specifies that practice engine failures may be conducted at a minimum altitude of 500 feet above the aerodrome, and that the ensuing approach must be terminated at a minimum height of 200 feet. An obstacle clearance climb is to be terminated at 300 feet above the aerodrome and a normal climb profile adopted. The operator considers that a practice engine failure during an obstacle clearance climb phase is unsafe and does not include such a training exercise. In addition, with a temperature of 22 deg C, the density altitude of 4783 feet could be expected to exacerbate the problems.

Factors

A high-density altitude prevailed.

The instructor initiated a training manoeuvre at a height and speed from which recovery was difficult.

The optimum aircraft configuration was not adopted during the power-off approach.

Visual approaches to Sydney Airport were in progress, domestic arrivals being processed for runway 34R, and international arrivals for runway 34L. The arrival sequence was being handled by Approach South (APP-S) and Approach North (APP-N) radar controllers. Traffic density was described as light to medium.

To resolve a traffic management problem in his airspace, APP-S coordinated with APP-N for a Metro 23 to complete a right circuit for arrival to runway 34R. This involved radar vectoring the aircraft to pass overhead Sydney Airport onto a right downwind leg, east of the runway complex, an area which was normally under the jurisdiction of APP-N. However, as there was no traffic east of the runway at the time, it was agreed to keep the Metro 23 on the APP-S frequency.

A SAAB 340 (SF34) was also being processed by APP-S for a landing on runway 34R and was given radar vectors to join on left downwind. During the arrival sequence, the crews of both aircraft were given instructions to descend to 2,000 ft and were vectored onto opposing headings for their respective base legs. Some coordination concerning other aircraft took place at about this time. When the Metro 23 was passing through the final approach path of runway 34R, the crew questioned the controller as to whether they were to turn the aircraft right to intercept final approach. APP-S confirmed this, then vectored the SF34 to remain clear of the Metro 23. Recorded radar data indicated the aircraft passed within 2 NM of each other, with a minimum vertical separation of 200 ft. The required radar separation standard was 3 NM laterally or 1,000 ft vertically.

The decision to leave the Metro 23 on the APP-S frequency, whilst being vectored within APP-N, airspace was considered to be a significant factor in the development of this occurrence. Whilst the APP-S controller believed he had not forgotten to issue the crew of the Metro 23 with a clearance to turn onto final approach, it appeared he had a mind-set, or expectancy, that APP-N would process the aircraft, as would normally happen. This mind-set was experienced despite the fact that the colour of the Metro 23's radar symbol indicated it was under the jurisdiction of APP-S.

The student pilot was making an approach for a normal landing. During the landing flare he raised the nose too high, and the aircraft ballooned. The student attempted to correct the situation by adding power and lowering the nose. The aircraft was no longer aligned with the runway and the student used the rudder to turn the aircraft. As he was completing this action the stall warning sounded. The student opened the throttle to full power, to go around, but he did not stop the aircraft from pitching more nose-up nor did he centralise the rudders. The aircraft stalled, pitched nose down and rolled to the left. The left wing and propeller struck the ground before the student could take any further action. The student turned the magneto and power switches off before leaving the wreckage.

The student's inexperience was the major factor in his misjudgement of the approach and his use of incorrect recovery action.

Whilst being hover taxied between hangars, in strong gusty wind conditions, the helicopter rotated rapidly to the right, struck the ground, and rolled onto its side. Both occupants were able to evacuate the machine without injury. The instructor pilot reported that the helicopter was being flown by the student pilot at the time.

With the wind gusting from the south, the aircraft was lifted into the hover on an easterly heading, then rotated to the right through 180 degrees. As it approached a westerly heading it swung rapidly to the right. Full left pedal and power reduction failed to arrest the rotation which continued for two or three turns before the helicopter struck the ground and rolled onto its side.

No mechanical defects were reported that may have contributed to the accident. It was the opinion of both the instructor pilot, and the operator's chief pilot, that the accident was consistent with the loss of tail rotor authority.

The pilot reported that a recent cyclone had blown a tree branch onto the strip. The branch was lying so that the top of one section was at least two metres above the ground. When he carried out a landing area inspection the pilot did not see the branch. He landed into the rising sun and did not sight the branch until it was too late to avoid it. The branch collided with the left-wing leading edge about a third of a metre in from the tip.

The airfield at which the aircraft was operating had a north/south strip, reported to be 800 metres long and an east/west strip, reported to be 1000 metres long. The wind was easterly at 10 to 15 kts. After despatching a load of parachutists, the pilot decided to land into the north. This involved using the shorter strip with a crosswind rather than landing on the longer strip into wind. He said he did this for two reasons. There was mechanical turbulence on short final approach for a landing into the east and after despatching the parachutists he was well positioned for a landing into the north. The north/south strip was more than long enough for landing.

Approach was at 70 knots with 40 deg of flap. While on approach, the pilot noticed a parachutist just off the left side of, walking parallel to, and approximately one third of the way along, the strip he was approaching. He continued approach but on very short final the parachutist started to walk across the strip. The pilot revved the engine to get the attention of the parachutist but when the parachutist finally saw the aircraft approaching, instead of immediately clearing the strip, he ran down the strip away from the aircraft for 20 to 30 metres before moving clear.

The pilot said he did not want to attempt a go-around because of powerlines off the end of the strip so he persisted with the landing, aiming to touch down just past the parachutist. The pilot said that after the initial touchdown, the aircraft bounced two or three times. Once on the ground, he applied full braking. The aircraft skidded, turned to the right and continued to skid out of control through a fence, finally coming to rest at the base of a tree.

It was reported that the pilot was hovering the helicopter in a 12-15 kt headwind, 10-15 ft above trees. Consequently, a less than average power setting was required to maintain height. The wind strength suddenly reduced, and the helicopter descended towards the trees. The pilot increased collective pitch and power to stop the descent and re-establish the hover. Although the helicopter came close to the tree tops the pilot did not believe there had been any contact with them.

Shortly afterwards, the pilot heard an unusual noise coming from the main rotor blades. He landed to investigate and found dents and holes in all three main rotor blades.