On 14 September 2014, the pilot of a Bell 206 helicopter, registered VH-FHX, conducted a charter flight from Myra mine camp, Northern Territory with 3 passengers on board. After arriving overhead a specified location, the pilot conducted an orbit at about 500 ft above ground level (AGL) to assess the area for a suitable landing site. The pilot then conducted a second orbit at about 100 ft AGL and noted the hazards including a tree stump to the left of the target landing area and a tall tree to the right.
The pilot then conducted an approach and a vertical descent into the selected landing site. When at about 1 ft AGL, a passenger alerted the pilot to the tree stump on the left. The pilot immediately manoeuvred the helicopter up and to the right, resulting in the helicopter striking a tree.
The pilot conducted a climb away from the site, an orbit and a second approach to land. After landing, the pilot shut down the helicopter and conducted an external inspection. The pilot assessed the damage to be minor and unlikely to affect the safety of the flight. After completing the charter flight and returning to Jabiru, the pilot inspected the helicopter and found the damage to the main rotor blade had worsened significantly. An engineer subsequently determined that the main rotor blade and tail rotor blade had sustained substantial damage and required replacement.
This incident highlights the challenges of operating in confined areas and the risks posed by distractions. It is also a reminder to ensure an aircraft is fully serviceable prior to flight, particularly following an incident.
On 7 September 2014 at about 1303 Australian Eastern Standard Time, a Piper Arrow, registered VH-KGP was completing a private, visual rules flight (VFR) from Orange to Wollongong, New South Wales. On board were a pilot and one passenger.
At about 10 NM north of Wollongong, the pilot broadcast an inbound call on the common traffic advisory frequency (CTAF). At the time, an instructor and student in an Evektor Sportstar registered 24-4467 were one of two aircraft conducting circuit training on runway 34.
The pilots of both KGP and 4467t communicated their respective position and intentions, and at 1306, the pilot of KGP called joining an extended downwind for runway 34.
When 4467 was on the crosswind leg for runway 34, the crew noted KGP on their left, about 100 metres ahead and at about the same level as them.
The instructor in 4467 initiated a climbing turn and shortly after, KGP passed underneath and just behind 4467.
This incident highlights the importance of using standard phraseology, and making extra calls when there is any uncertainty regarding another aircraft’s position when operating at non-controlled airports. As well as a requirement, it is good airmanship given the limitations of the See-and-Avoid Principle.
On the morning of 14 September 2014, the pilot and passenger of an amateur-built Van's Aircraft RV-6, two-seat aeroplane, registered VH-TXF and operated in the ‘Experimental’ category, approached Mudgee Airport. The aircraft had departed Dubbo Airport, New South Wales about 25 minutes earlier.
The pilot approached from the north-west and conducted a non-standard circuit entry including an orbit to the south of the airport. Prior to turning onto the downwind leg of the circuit, the aeroplane descended to about 600 ft above ground level. Witnesses stated that the pilot conducted a tight left turn onto final approach at a slow speed and low height. The witnesses also recalled hearing the aeroplane’s engine ‘splutter’ and then silence during the turn, followed by a ‘rev’ followed again by silence.
The aeroplane continued its high angle of bank left turn and, at about 1053, collided with terrain about 300 m south-west and short of the runway threshold. The pilot and passenger were fatally injured, and the aeroplane was substantially damaged.
What the ATSB found
The ATSB found that during the turn onto final approach to land, the aeroplane’s engine ceased operating. The aeroplane’s airspeed before the engine failure was within about 0.5 kt of the estimated stall speed during the high-bank turn. After the engine failure, it is likely the aeroplane entered an aerodynamic stall. The associated loss of control was not recovered, and the aircraft continued in the turn until it collided with terrain.
The ATSB also found that the engine failure was probably due to carburettor icing. No defects were identified that would have precluded normal engine operation prior to the accident, and uncontaminated fuel was being supplied to the engine at that time. However, the environmental conditions at the time of the accident were conducive to serious carburettor icing at descent power, and the pilot-operated carburettor heat control was found in the OFF position.
Analysis of the aeroplane’s global positioning system data showed that it was common for this pilot to fly approaches at lower than recommended circuit heights and at speeds close to the aircraft’s stall speed. On the turn to final approach on the accident flight, any loss of airspeed would have left a very short time before the aeroplane reached the stall speed.
The ATSB also found that the aeroplane’s weight was higher than the design limits. However, the effect of this weight on aircraft performance was not considered to have contributed to the accident.
The aeroplane was not required to be, and was not fitted with an angle-of-attack indicator or stall warning device.
Safety message
All pilots of aircraft fitted with a carburettor are advised to check the forecast weather conditions and consider the risk of carburettor icing as a result of those conditions prior to each flight.
Although amateur-built aeroplanes operated in the Experimental category are not required to be fitted with a stall warning device, owner-pilots should consider the benefits of such devices as a last line of defence against the inadvertent approach to, or entry into an aerodynamic stall.
Source: ATSB
The occurrence
At about 1024 Eastern Standard Time[1] on Sunday 14 September 2014, the pilot and passenger of an amateur-built Van's Aircraft RV-6 aeroplane, registered VH-TXF, departed Dubbo Airport on a private flight to Mudgee Airport, New South Wales.
At about 1049 the pilot approached Mudgee Airport from the north-west and conducted a nonstandard circuit entry. This included an orbit to the south of the airport. Airport audio recordings of aircraft broadcasts show that throughout the arrival at Mudgee, the pilot made all of the standard radio calls, including traffic advice of joining crosswind, base leg, and final approach for runway 04.[2] The pilot did not make any broadcasts suggesting any problems with the aircraft.
Prior to turning onto the downwind leg of the circuit, the aeroplane descended to about 600 ft above ground level. Witnesses stated that they saw the aeroplane turn left at about 45° angle of bank onto final approach at a slow speed and at a lower height than usual. The witnesses also recalled hearing the aeroplane’s engine ‘splutter’ and then silence during the turn, followed by a ‘rev’ followed again by silence.
The aeroplane continued its high angle of bank left turn beyond the final approach heading and, at about 1053, collided with terrain about 300 m south-west and short of the threshold of runway 04(Figure 1 and Figure 2). No witnesses reported seeing the aeroplane impact the terrain.
The pilot and passenger were fatally injured, and the aeroplane was substantially damaged.
Figure 1: Aerial view of the accident site on the day, showing the threshold of runway 04 and direction of travel prior to impact
Source: NSW Police Force, modified by the ATSB
Figure 2: Accident site, looking east-south-east and showing the airport boundary fence
The pilot held a Private Pilot (Aeroplane) Licence and the appropriate ratings and endorsements to operate the Van's Aircraft RV-6 (RV-6). The pilot also held a valid Class 2 Aviation Medical Certificate, which was sufficient for the pilot to exercise the privileges of their licence.
The last recorded entry in the pilot’s logbook was on 14 June 2014. A review of the pilot’s logbook and aircraft maintenance release for VH-TXF (TXF) indicated that the pilot had accrued a total of about 764 hours flight time. The pilot’s most recent biennial aeroplane flight review was on 9 June 2014.
A flying instructor who had flown with the pilot stated that the pilot was very aware of the risk of carburettor icing, and was in the habit of using carburettor heat at lower power settings.
Recent history
The only recorded flying by the pilot in the week prior to the accident was a 2.9-hour flight from Traralgon, Victoria, to Dubbo on 12 September 2014. Friends of the pilot reported that, on the evening before the accident, the pilot retired at about 2200, and was observed outside the hotel room the next morning at about 0800. There was no evidence that fatigue contributed to the accident.
Aircraft information
General information
TXF was a two-seat Van's Aircraft RV-6 aeroplane, and was manufactured by the pilot from a kit. It was first registered in Australia on 10 July 2001 and the kit was completed in 2006 (serial number 24677). TXF had accumulated about 425 hours total time in service at the time of the accident.
The aircraft was operated in the ‘Experimental’[3] category.
Maintenance history
Examination of the aeroplane’s maintenance records indicated that it was maintained to a day visual flight rules[4] standard in the experimental category. The last periodic inspection was completed on 16 December 2013, and a maintenance release was issued at that time. At the time of the accident, all of the required maintenance had been completed and there were no outstanding recorded defects.
Weight and balance
The aircraft kit manufacturer-published recommended gross weight for the RV-6 was 727 kg. This was also detailed on the aircraft’s data plate.[5] The pilot had generated their own weight and balance calculation paperwork, which detailed a maximum allowable gross weight of 748 kg. This paperwork, which the pilot carried in the aeroplane, indicated that the aeroplane’s gross weight on departure from Dubbo was 740 kg and was planned at about 731 kg on arrival at Mudgee.
The ATSB calculated that the aeroplane was about 4 kg over the manufacturer-recommended gross weight on arrival at Mudgee. However, according to the pilot’s paperwork, the aeroplane was within the pilot’s calculated flight envelope. The ATSB could not identify any data to indicate how the pilot determined the new gross weight for the aircraft. A calculation was performed by the ATSB to examine the effects of the weight increase on the aeroplane’s aerodynamic stall speed.[6] This calculation indicated that the aeroplane’s stall speed would have increased by about 0.5 kt.
Meteorological information
The observed weather at Mudgee Airport at the time was fine with a 6 kt breeze from the north and no cloud in the vicinity. The recorded temperature at about the time of the accident was 17 °C, with a dew point[7] of 11 °C. Given those temperatures, the probability of carburettor icing was calculated to be in the serious icing range for descent power, and moderate icing with cruise power selected (see appendix A – Carburettor icing-probability chart, available from the Civil Aviation Safety Authority (CASA) website).
Wreckage examination
Overview
The aeroplane struck the ground in a north-westerly direction, coming to rest about 18 m beyond the initial impact point. The impact collapsed the aeroplane’s fixed landing gear, damaged the engine, carburettor and air filter and ruptured the left wing fuel tank. The damage to the aeroplane and surrounding area indicated that the aeroplane impacted the ground in an upright, slightly leftwing low and nose-down attitude. All of the aeroplane’s major components were accounted for at the site. No evidence of fire or pre-impact damage was observed and flight control continuity was verified.
One blade of the aeroplane’s two-bladed wooden propeller was broken off at the root and shattered (Figure 3). The other blade remained attached to the hub. The unbroken blade and metal spinner that covered the propeller hub exhibited no evidence of rotational scratch marks or power at impact.
Figure 3: Broken two-bladed propeller blade and metal spinner, showing the reconstructed detached/shattered blade
Source: ATSB
The engine and a number of other items and components from TXF were recovered for technical examination at an approved engine overhaul facility and at the ATSB’s technical facilities in Canberra, Australian Capital Territory. This included a portable Garmin GPSMAP 296 global positioning system (GPS) receiver.
Fuel
The left fuel tank was breached along a rivet line, consistent with impact forces. Witnesses reported fuel running from the rivet line before being plugged by the attending fire service.
On examination by the ATSB, about 20 L of fuel remained in the left fuel tank and about 65 L in the right fuel tank. The fuel tank selector in the cockpit was selected to the right tank. Fuel was observed:
throughout the fuel system through to the engine-driven fuel pump
to run from the damaged carburettor bowl and its filter screen
to be free of debris and water throughout the aeroplane’s fuel system, and of a colour and odour that was consistent with aviation gasoline.
The ATSB concluded that fuel starvation or contamination did not contribute to the loss of engine power.
Survivability
The aeroplane was fitted with a 5-point harness for each seating position and both occupants were wearing their harness. The lap belts and crotch straps remained anchored to the floor and the shoulder harnesses were appropriately anchored to the fuselage structure behind the occupant’s seats and luggage area. ATSB analysis based on estimates of aircraft speed, impact angle, and energy absorption indicated that the impact forces imparted to the occupants would normally be expected to result in serious to fatal injuries.
During the impact sequence, the sides of the cockpit buckled, reducing the liveable space and allowing the fuselage behind the pilot and passenger to move forward (Figure 4). As a result, both occupants’ shoulder harnesses slackened and the occupants were no longer adequately restrained. Together with the effect of the estimated impact forces imparted to the occupants, this reduction in liveable space meant that the accident was considered not survivable.
Figure 4: Cockpit region showing buckling alongside the left and right seats
Source: ATSB
Engine and associated components examination
The aeroplane’s engine and associated components were removed and taken to an approved engine overhaul facility for disassembly and detailed examination under the supervision of the ATSB. No evidence was found to suggest abnormal engine operation prior to the impact with terrain. The engine’s two magnetos[8] and associated spark plugs performed correctly when examined and operationally tested on their respective test rigs.
Recorded data
Recorded data from the aircraft’s portable Garmin GPSMAP 296 GPS, including of the accident flight, was successfully downloaded at the ATSB’s technical facilities. This data included a series of points indicating the aeroplane’s latitude and longitude, altitude and the respective dates and times of those records.
The data for the day of the accident commenced at about 1019 and showed the path taken by the pilot from start-up at Dubbo Airport to the approach at Mudgee Airport. ATSB analysis of this data determined the aircraft’s height above ground, ground speed and heading at the various data points. This included the circuit entry at Mudgee, a southerly, figure eight-like orbit prior to the aeroplane joining the downwind leg of the circuit and the turn onto final approach to land as described by witnesses (Figure 5).
Figure 5: ATSB analysis of the recorded GPS data for the flight showing the aircraft’s heading, height above ground, and ground speed at various data points. The area of the southerly, figure eight-like orbit is indicated by a dashed blue border
Source: Google earth, modified by the ATSB
Data recovered from the aircraft’s Garmin GPSMAP 296 GPS also provided the flight path details for a number of previous flights, up to, and including the accident flight. Circuit entry procedures were compared between flights carried out in 2014 to better understand the pilot’s usual handling of the aeroplane from entering the circuit, through to the landing. None of the approaches analysed displayed a similar figure eight-like orbit prior to joining the crosswind leg as was done on arrival at Mudgee (Figure 5).
A review of the accident and 22 previous final approaches was performed using the recorded GPS data and wind information from the aerodromes visited by the aircraft during those flights. The review found that on 18 occasions, the aeroplane was below 500 ft at the beginning of the final approach and, on 11 of the 22 final approaches, below the target approach speed of 63 kt (see Aeroplane approach speed considerations) on joining the final leg of the circuit. On 10 of the 18 occasions when the aeroplane was below 500 ft at the beginning of the final approach, it was also below the target approach speed of 63 kt.
At the estimated arrival gross weight of 731 kg the aircraft had a stall speed of 48 kt. Turning onto the final leg of the circuit at Mudgee, as derived from the GPS data, the aircraft had:
a bank angle of about 48°
a descent rate of 1,770 ft/min
an airspeed of 59 kt (4 kt below the target approach speed)
an accelerated stall speed of 58 kt.
In combination these findings indicated that the aeroplane’s airspeed was about 1 kt above the calculated accelerated stall speed, or within about 0.5 kt when considering the aeroplane’s increased weight, which was above the kit manufacturer’s recommended gross weight.
Additional information
Carburettor icing
Carburettor icing[9] can occur in temperatures up to about 38 °C, and is less likely in very cold climates. Increased humidity increases the likelihood of icing. If ice continues to accumulate within the carburettor, the flow of air into the engine reduces and eventually, if the process is allowed to continue, the engine will stop.
Carburettor icing is more pronounced if the engine is operating at a low power setting. In this case, the airflow through the carburettor is partially-impeded by the throttle butterfly valve. This valve provides more area on which the ice can accrete and increases the partial vacuum downstream of the valve. This causes further chilling of the air and the water droplets, further increasing the likelihood of ice accretion.
For aircraft with fixed pitch propellers, as ice forms there is typically a small decrease in engine RPM but the engine may continue to run smoothly. As ice continues to accumulate, the reduction in RPM continues and the engine will begin to run rough. If the icing conditions are severe enough, and the pilot takes no remedial action, the engine will eventually fail.[10]
A carburettor heat control was available in TXF. If selected, warm air was directed from a heat muff[11] installed on the exhaust system to the carburettor inlet, melting any ice in the venturi.
During the on-site examination, the carburettor heat control was identified in the OFF position (pushed in). It is possible that the impact sequence may have depressed the carburettor heat control. However, surrounding push/pull controls were undisturbed in their pulled-out positions.
The environmental conditions and time between the accident and the ATSB’s examination of the wreckage meant that any icing in the carburettor throat would have melted and not been detectable during that examination.
On 24 October 2014, the aeroplane kit manufacturer released a notification to RV-6 owners to inspect their heat muff installations for the correct installation of a vent screen. If placed in the wrong position, there was a chance that the screen may obstruct warm airflow to the carburettor, hindering the ability to remove carburettor ice and/or reduce engine performance. Examination of the exhaust system in TXF confirmed that the heat muff installation was a different type to that specified in the notification, which was therefore not applicable.
Aerodrome circuit entry procedures
Among other guidance, CASA Civil Aviation Advisory Publication (CAAP) 166-1(3) Operations in the vicinity of non-controlled aerodromes strongly recommended the use of standard circuit procedures at all noncontrolled aerodromes.[12] Standard traffic circuit procedures were designed to facilitate orderly flow of aircraft traffic. Given these standard traffic circuit procedures, other aircraft operating in the vicinity of the aerodrome would have a reasonable expectancy of where to locate other joining and circuit traffic, informing affected pilots’ ‘see and avoid’ procedures (Figure 6). The traffic entry procedure generally consisted of overflying the aerodrome to ascertain the wind direction and which runway was in use by other aircraft, before joining a circuit pattern for landing.
Approach speeds are based on the aeroplane’s aerodynamic stall speed. A safety margin of generally 1.3 times the aeroplane’s aerodynamic stall speed in the landing configuration is applied to determine an aircraft’s approach speed.
The kit manufacturer’s published stall speed for the RV-6 at 1 g[13] and a gross weight of 727 kg was 48 kt. Therefore, in an RV-6 at the recommended gross weight, the calculated approach speed would have been about 63 kt. As the g load is increased, as it generally would in a turn, the stall speed also increases. This is known as an accelerated stall.
Stall warning devices
Certified aeroplanes were required to have a stall warning. This could be satisfied by either the inherent aerodynamic qualities of the aeroplane, or by the installation of a technical device that gives clearly distinguishable indications of an aerodynamic stall under the expected conditions of flight.[14]
The Unites States Federal Aviation Administration issued InFo[15] 14010 on 14 July 2014. This document recommended the installation and use of angle of attack (AoA)-based systems to reduce the risk of inadvertent aerodynamic stall that may result in a loss of control accident. The kit manufacturer did not produce a stall warning kit specific to the RV-6, but did encourage builders and owners to consider installing AoA indicators.
TXF was not fitted with a stall warning device or an AoA indicator, nor was it required to be as it was not a certified design. This meant that the only stall warning available to the pilot was via the aircraft’s aerodynamic qualities.
The stall characteristics for each individual aeroplane of an amateur-built type depend to an extent on the precision of the aeroplane build. This necessitates the completion by the pilot of stall testing for the aeroplane and recording the results in the aircraft’s flight manual. The flight manual for TXF was not able to be located to verify the stall speed characteristics as compared to those of the kit manufacturer.
From witness information and examination of the accident site, it is evident that during the turn onto final approach, the pilot lost control of the aeroplane and was unable to recover before impacting the ground. The observed departure from controlled flight was consistent with an aerodynamic stall.
This analysis will consider the factors with the potential to have contributed to the loss of control.
Interpretation of the flight path
The ATSB did not identify any issues that would have required the pilot to orbit to the south of the aerodrome as shown on the global positioning system (GPS)-derived flight path profile. Although unable to be confirmed, it was possible that the pilot manoeuvred to view their accommodation, which was just to the south of the runway. Whatever the reason for the orbit, the ATSB believes that it was unrelated to the accident.
Engine operation
The witness accounts of the engine being silent during the turn onto final approach, and the lack of rotational signatures on the propeller, indicates that the engine was not operating when the aeroplane collided with terrain. No defects were identified that would have precluded normal engine operation prior to the accident, and uncontaminated fuel was being supplied to the engine at that time.
Conditions around the time of the accident were conducive to serious carburettor icing at descent power, such as during the circuit and approach onto final. In combination, the as-found positions of the carburettor heat control in the depressed OFF position, and of the surrounding push/pull controls in the pulled-outed positions, were consistent with the carburettor heat control being in the OFF position before impact. In this case, it is probable that the air temperature in the carburettor was in the icing range and that carburettor ice would have formed. Although the pilot was reported in the habit of using carburettor heat at lower power settings, it is possible they forgot on this occasion, or were not aware of the suitability of the environmental conditions for carburettor icing.
Witnesses reported only hearing unusual engine sounds during the pilot’s turn from downwind onto final approach. It is considered unlikely that there was a detectable performance issue prior to that turn because, had that been the case, the pilot would probably have modified their circuit to attempt an earlier forced landing on either of the available runways. Recovery from an engine failure at greater height allows for increased landing options. However, the witness reports of the pilot’s apparent attempt to restart the engine on final approach would suggest that any carburettor icing remained undetected throughout the join and initial legs of the circuit.
In the absence of contradicting evidence, and considering the witness observations, ambient conditions that were conducive to carburettor icing and lack of any indication of propeller rotation at impact, the ATSB concluded that it was probable the engine failed during the final turn due to carburettor icing.
Weight and balance
The evidence indicated that the pilot was operating the aeroplane above the kit manufacturer’s recommended gross weight and above the gross weight as stated on the aeroplane’s data plate. The use of extrapolated data outside the recommended flight envelope is not considered accurate, precluding a full understanding of the effect on the aircraft’s performance. However, using the gross weight figure recorded on the pilot’s flight planning documentation to estimate the aircraft’s centre of gravity suggested that the aircraft was within the kit manufacturer’s recommended limits.
Given the aircraft was being operated above its limiting gross weight, wreckage examination found no evidence of an in-flight structural failure. As a result, the most probable effects of the operation outside the kit manufacturer’s recommended maximum gross weight were a slightly increased stall speed and likely increased difficulty during recovery from a loss of control.
Approach speed consideration
Based on the recorded GPS flight data, the pilot commonly flew their approaches at lower than recommended circuit heights and at speeds close to the aircraft’s stall speed. On the accident flight, the stall margin was significantly reduced throughout the last 48° angle of bank turn, being within about 0.5 kt of the aircraft’s stall speed.
Any loss of airspeed in those conditions left a very short time before the aeroplane reached its stall speed. Given that the engine failed during the steep angle of bank and low speed turn onto final approach, it is probable that the aeroplane entered an accelerated aerodynamic stall soon after the engine failure, from which the pilot was unable to recover before colliding with terrain.
Findings
From the evidence available, the following findings are made with respect to the collision with terrain involving a Van's Aircraft RV-6, registered VH-TXF that occurred near Mudgee Airport, New South Wales on 14 September 2014. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing factors
As the aircraft was turned on to the final approach to land, the engine ceased operating.
The meteorological conditions at the time of the accident were conducive to carburettor icing, which probably led to the engine stopping.
The steep turn onto the final approach at low airspeed probably resulted in an accelerated aerodynamic stall shortly after the loss of engine power from which the pilot was unable to recover before impacting terrain.
Other factors that increased risk
The aeroplane was not fitted with a stall warning device or angle of attack indicator, increasing the risk of inadvertent aerodynamic stall.
The aeroplane was being operated at weights above the kit manufacturer’s recommended gross weight.
Sources and submissions
Sources of information
The sources of information during the investigation included the:
pilot’s previous flying instructors
aircraft kit manufacturer
Civil Aviation Safety Authority
United States Federal Aviation Administration
New South Wales State Coroner
New South Wales Police Force.
References
Australian Transport Safety Bureau, 2001, Melting Moments: Understanding Carburettor Icing, Educational fact sheet.
Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety Investigation Act 2003 (the Act), the ATSB may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to make submissions to the ATSB about the draft report.
A draft of this report was provided to the Civil Aviation Safety Authority.
No submissions were received.
Appendices
Appendix A – Carburettor icing-probability chart
Source: Civil Aviation Safety Authority
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
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
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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.
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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.
On 17 July 2014 a Malaysia Airlines Boeing 777-200, registered 9M-MRD, en route from Amsterdam in the Netherlands to Kuala Lumpur, Malaysia, disappeared from air traffic services radar overhead the Ukraine. Aircraft wreckage was subsequently identified over a large area to the south and west of the village of Hrabove, eastern Ukraine. There were no survivors.
As the occurrence took place in the Ukraine, the National Bureau of Air Accident Investigation of Ukraine (NBAAI) commenced an accident investigation under Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation (Annex 13) on 17 July 2014. As part of its investigation, the NBAAI requested assistance from the Australian Transport Safety Bureau (ATSB) and under clause 5.23 of Annex 13, the ATSB appointed an accredited representative and an adviser to the NBAAI investigation on 20 July 2014. In addition, an external investigation was initiated under the provisions of the Australian Transport Safety Investigation Act 2003.
The ATSB investigators departed for Kiev, Ukraine on 21 July 2014 to participate in the NBAAI accident investigation. Subsequently, on 23 July 2014, the Ukrainian Government delegated the conduct of the investigation to the Dutch Safety Board (DSB) under clause 5.1 of Annex 13. The ATSB investigators remained in Kiev to assist the Dutch investigation before relocating with the investigation team to the DSB headquarters in the Netherlands on 1 August 2014. The ATSB investigators returned to Australia on 8 August 2014.
During the investigation the ATSB and other accredited representatives contributed to the development of the DSB’s preliminary investigation report, which was released to the public on 9 September 2014. In addition, the ATSB representative attended two investigation progress meetings in The Netherlands. The second of these meetings included an examination of the reconstruction of the aircraft from recovered wreckage, items and components.
Subsequently, and consistent with Annex 13 standards and recommended practices, the ATSB and other accredited representatives received a copy of the draft investigation report for comment. The DSB considered these and comments from other relevant parties to the investigation before finalising their report.
The DSB has completed its investigation and report and, in accordance with the provisions of Annex 13, a final investigation report was published 13 October 2015. This report, together with information on the investigation, is available from the DSB’s website at www.onderzoeksraad.nl/en.
Any enquiries with respect to the DSB investigation should, in the first instance, be directed to:
On 5 September 2014, the pilot of a Mooney M20J aircraft, registered VH-JDY, conducted a solo training flight from Jandakot Airport to Northam aeroplane landing area (ALA), Western Australia. After a touch-and-go on runway 14 at Northam, the pilot conducted a second circuit with a missed approach from about 600 ft on final. The pilot then intended to conduct a third circuit with a touch-and-go. When on final, the pilot trimmed the aircraft in the approach configuration with full flaps (33°) and airspeed at about 70 kt.
The pilot flared the aircraft for landing and touched down about one third of the way along the runway. As the aircraft slowed, the pilot selected the flaps to 15° and applied full throttle along with right rudder to counteract the aircraft’s tendency to yaw left. As the airspeed increased to about 65 kt, the pilot rotated the aircraft for take-off and applied forward pressure against the control column as the aircraft nose tendency was to pitch up due to the combination of trim, flap and power settings.
When at about 50 ft above ground level, the aircraft had drifted to the right of the runway centreline and the pilot reduced the right rudder input. Soon afterwards, the aircraft nose pitched up. The stall warning sounded and the pilot applied full right rudder and pushed forward on the control column in an attempt to level the aircraft wings and recover from the stall. The left wing dropped as the aircraft stalled, and it collided with a hangar. The aircraft pivoted about the left wing and came to rest wedged between two hangars resulting in substantial damage.
On 3 September 2014, at about 0215 Eastern Standard Time (EST),[1] a Fairchild SA227 aircraft, registered VH-UUO, took off from Brisbane Airport, Queensland for a freight charter flight to Bankstown Airport, New South Wales, with one pilot on board. Following the take-off, when at about 200 ft above ground level, the pilot observed the horizontal situation indicator (HSI) indicating a right turn although the aircraft was still maintaining runway direction. The pilot reported that the attitude indicator (AI) displayed alternately a nose up and nose down attitude.
When at about 1,600 ft above ground level, the pilot advised air traffic control of a ‘minor problem with heading’ and was directed to conduct a right turn onto an easterly heading to avoid noise sensitive areas. The pilot turned the aircraft to the right, towards the Pacific Ocean, while referring to the HSI on the co-pilot’s instrument panel, which was providing more accurate heading information. The pilot was aware that the captain’s AI and HSI instruments were providing erroneous indications, but became disoriented by continuing to scan those instruments. The pilot looked out of the window in an attempt to gain a visual reference but could see only blackness.
The pilot continued a shallow right turn until the lights of runway 19 became visible. The aircraft landed back at Brisbane, on runway 19 about 150 kg above the aircraft’s maximum landing weight.
What the ATSB found
The ATSB found that the cockpit was not configured correctly prior to taxi, nor was the incorrect heading reference detected or corrected during the taxi or line up. The left gyro slaving switch was selected to ‘free’ instead of ‘slave’ mode, resulting in the captain’s HSI indicating about 50° left of actual heading throughout the flight.
The AI probably intermittently malfunctioned after take-off, and the pilot became distracted by the two erroneous instrument indications. These, combined with the dark night and flight over water without visual reference, contributed to the pilot’s difficulty in maintaining orientation and achieving the planned departure track. The pilot therefore elected to return to land at Brisbane.
What has been done as a result
The aircraft operator developed a simulator exercise based on the incident, to ensure all company pilots demonstrated limited instrument panel skills – without reference to attitude indicator or direction indicator, and troubleshooting skills.
Safety message
This incident highlights the importance of completing pre-flight checks and ensuring the cockpit is correctly configured prior to taxiing. Particularly when operating at night or into instrument meteorological conditions, it is imperative to verify all reference instruments are indicating correctly. This incident also highlights the importance of communication, especially as emergencies arise. If a pilot is having difficulty controlling an aircraft and maintaining instrument or visual reference, then alerting air traffic control enables them to provide the necessary and appropriate assistance.
[1] Eastern Standard Time (EST) was Coordinated Universal Time (UTC) + 10 hours.
On 25 August 2014, a QantasLink Bombardier DHC-8 aircraft, registered VH-LQK was being prepared for a scheduled passenger flight to Blackall and then Longreach, from Brisbane Airport, Queensland. Ground handlers loaded bags into the aircraft in accordance with the load instruction report: 12 bags with destination Blackall and 47 bags for Longreach in hold 41; 20 bags for Longreach in hold 42; and nil bags or cargo in locker 11.
A ground handling agent transcribed the baggage information onto a call back card, but indicated there were 12 bags in hold 41 instead of 59 bags. The call back card was then provided to the flight crew, who entered the baggage information into the iPad loading application to complete the final load sheet.
The aircraft arrived in Blackall at 0915 Eastern Standard Time. A ground handler at Blackall completed the offload reconciliation procedure and identified a discrepancy of 47 bags or 676 kg in hold 41. The aircraft remained within centre of gravity limits and no structural limits were exceeded.
Data input errors, such as the incorrect loading figures being used, occur for many different reasons. The consequences of these errors can include a range of aircraft handling and performance issues.
Accurate weight and balance information is essential for the safety of every flight. Following standard procedures and checklists minimise the potential for error.
On the afternoon of 25 August 2014, the pilots of two Robinson R22 helicopters were ferrying the helicopters from Yeeda to Springvale via a refuelling stop at Leopold Downs, within the Kimberley region of Western Australia. The pilot who was ahead by about 10 NM (18 km) arrived at Springvale about 40 minutes after last light but the pilot of the second helicopter, registered VH‑YPC, did not arrive as expected.
A search using helicopters began early the next morning and the overdue helicopter was soon found in a seriously damaged state, close to the intended track and 25 NM (46 km) west of Springvale. The pilot had been fatally injured.
What the ATSB found
The ATSB found that the pilot of VH-YPC, who did not hold a night visual flight rules (VFR) rating or instrument rating, continued flying towards the destination after last light (end of civil twilight), then in dark night conditions without local ground lighting, inadvertently allowed the helicopter to descend into terrain.
Safety message
This accident highlights the inherent high risk of night flying in remote areas due to the absence or degradation of the visual references for establishing an aircraft’s attitude and position. This risk is increased to unacceptable levels when night flying is attempted by pilots without night VFR or instrument flying qualifications. To avoid the usually fatal consequences of disorientation, day VFR pilots need to plan to arrive at their destination at least 10 minutes before last light and to have a realistic ‘Plan B’ to use when it becomes apparent that an intended flight cannot be completed in daylight. It is important, also, for operators and others involved in the operation of aircraft to actively support safety-first pilot decision making.
The ATSB is concerned about the frequency of accidents – many fatal – that involve pilots flying with reduced visual cues. This has been highlighted on the ATSB website as a SafetyWatch priority along with a number of strategies to help manage the risk and links to relevant safety resources.
This preliminary report details factual information established in the investigation’s early evidence collection phase and has been prepared to provide timely information to the industry and public. Preliminary reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.
The Occurrence
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 initial 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.
MTM Service 6502
At about 1840 on 22 August 2014, Metro Trains Melbourne (MTM) passenger train 6502 departed Werribee Railway Station on its scheduled service to Flinders Street Station. The train arrived at Laverton Railway Station at about 1852 without incident.
Figure 1: Location map – Greater Melbourne
Source: Copyright Melway Publishing 2013, Edition 41 with annotations by the Chief Investigator, Transport Safety (Victoria)
The train departed Laverton Railway Station and all signal aspects from Laverton were at clear normal speed (Green over Red). At about 1855, the train achieved a maximum speed of 115 km/h — the maximum authorised line speed for this section of track. The train then passed signal GG630 (Figure 2) that was also indicating a clear normal speed aspect, and had just crossed over Cherry Creek, when the driver heard a ‘loud bang’ from under the train. He noted that the brake pipe pressure had decreased and the brake cylinder pressure had increased. There was an immediate reduction in speed and the driver placed the brake handle to the full service braking position. When the train came to a stop, he placed the Reverser to the off position, which automatically applied the spring park brake. The train came to a stop at 1855, with the rearmost car, 427M, at about the 16.53 rail km mark.
The driver looked back and concluded that the train had not derailed and that it was not fouling the adjacent running lines. He called Metrol to advise them of the location of the train and that the train had lost brake pipe pressure. He then made an announcement on the public address system to the passengers to advise them that the train would be delayed due to a defect. The driver then called Metrol for authority to go on the track.
Figure 2 – Collision location and signals
Source: Metro Trains Melbourne with annotations by the Chief Investigator, Transport Safety (Victoria)
V/Line Service 8280
At about 1802 on the same evening, V/Line train 8280 departed Geelong for Southern Cross Railway Station. The train was returning to Southern Cross Station in preparation for a scheduled passenger service, and it was crewed by a driver and a conductor but carried no passengers. At about 1832 the train came to a stand at Automatic signal GG1178 (between Little River and Werribee) which was at Stop and resumed its journey about 19 seconds later. After passing through Laverton Station, it proceeded at about 90 km/h past Automatic signal GG672 which was indicating a normal speed warning (Yellow over Red). The train then arrived at Automatic signal GG630 which was indicating a Stop aspect (Red over Red) and stopped for about eight seconds before resuming its journey. Trains are allowed to proceed past an Automatic signal at Stop under conditions specified by a rule in The Book of Rules and Operating Procedures 1994.
The collision and post collision events
After passing signal GG630 the V/Line train reached a speed of 43 km/h and collided at this speed with the rear of the stationary MTM service 6502 at about 1901. The MTM train was shunted about 30 metres due to the impact and the impacted cars stopped at about the 16.5 rail km mark, approximately 1210 m from signal GG630. The driver of the MTM train was thrown onto the cab floor by the impact. The V/Line driver was trapped between the train control console and the seat but managed to extricate himself by lowering the seat. He got out of his cab, walked towards the MTM train and spoke to passengers to inquire as to their wellbeing and then spoke to the MTM driver who was still in the cab of his train.
The driver and conductor on the V/Line train, the driver of the MTM train and four passengers from the MTM train sustained minor injuries in the incident. Both trains sustained significant damage (Figure 3 & 4).
Figure 3 – Impacted trains
Source: Chief Investigator, Transport Safety (Victoria)
Figure 4 - Train damage
Source: Chief Investigator, Transport Safety (Victoria)
Context
Location
The collision occurred on the MTM rail network between the Maidstone Street and Kororoit Creek Road level crossings in Altona.
Figure 5 - Location of collision
Source: PASS Assets (Public Transport Victoria) with annotations by Chief Investigator, Transport Safety
Track and environmental conditions
The track infrastructure in this section consisted of a Broad Gauge East Line, a West Line and an independent parallel Standard Gauge line (Figure 2). Both trains were operating on the West Line. From the Maidstone Street level crossing the track is tangent with a slight downhill gradient towards Cherry Creek and Kororoit Creek level crossing. Clear sighting is available up to and beyond Cherry Creek from the Maidstone Street level crossing. The weather conditions were fine and it was a clear night with light winds.
Train and crew information
MTM Train and Crew
The MTM train 6502 was of the Comeng type and consisted of two, 3-car sets, 338M - 1092T - 484M and 487M - 1052T - 427M.
The MTM driver at the time of the incident had about 2½ years train driving experience. He held the required qualifications to operate the train, was route certified and assessed as medically fit for duty.
Following the collision the MTM train driver underwent mandatory drug and alcohol testing, the results of which were negative.
Post incident inspection and testing revealed that the train’s rear tail lights were operational.
V/Line Train and Crew
The V/Line train 8280 was a VLocity Diesel Multiple Unit consisting of VL05 (units 1105 and 1205), VL12 (units 1112 and 1212) and VL39 (units 1139, 1339 and 1239).
The V/Line train had two crew members, a driver and a conductor. The driver had been driving trains since qualifying in 1989 and was employed as a train driver by V/Line for the last 11 years. He held the required qualifications to operate the train, was route certified and assessed as medically fit for duty.
Post incident testing indicated that the trains head lights were operational and the train’s data logger indicated that the train’s headlights were on at the time of the incident.
Signalling system and rules
A three position colour light signalling system is in place between Laverton and Newport. Three position signals provide information to drivers regarding the compliance speed for the block and information on the the aspect of the signal ahead. Multiple aspect signalling allows closer spacing of signals such that braking distances are spread over two signal blocks, allowing higher line speeds for the sector and can consist of Home (Absolute) and Automatic signals (Permissive).
Home signals are usually directly controlled by a signaller or train controller as well as by track circuits. Home signals are Absolute signals and are not to be passed when displaying a Stop aspect unless written or verbal authority is provided as specified in the Book of Rules and Operating Procedures 1994.
Automatic signals are not directly controlled by a signaller or train controller but by the passage of trains (track circuits) and their function is to provide separation between trains travelling in the same direction on the same track in accordance with the line speed and headway requirements of that section of track.
A Permissive signal is an Automatic signal that is able to be passed at Stop under conditions specified by a rule in The Book of Rules and Operating Procedures 1994.
Ongoing investigation activities
The ATSB investigation is continuing and will focus on the:
Operation of the signalling system.
Operating rules pertaining to Permissive signalling systems and compliance.
Use of Permissive signalling systems in other jurisdictions.
Previous incidents associated with Permissive signalling systems.
Performance of train external lighting systems.
Use of safety technologies to maintain train separation.
Crashworthiness performance of the trains.
Mechanical condition of the trains, actions of the train crew and situational factors.
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
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.
Final report
Safety summary
What happened
At about 1901[1] on 22 August 2014, a V/Line train travelling the Werribee line on the Melbourne Metropolitan Rail Network collided with a stationary Metro Trains Melbourne (MTM) passenger train between Maidstone Street level crossing and Kororoit Creek Road. The MTM train had come to an unintended stop due to a loss of air pressure in its braking system. The V/Line train had stopped at an Automatic[2] signal that was indicating a Stop aspect and after a short while proceeded past the stop signal. Trains can proceed past an Automatic signal at Stop under conditions specified by an operating rule. Shortly after passing the signal, the train collided with the rear of the stationary MTM train at 43 km/h. The MTM train was carrying 51 passengers at the time of the collision. The driver and conductor on the V/Line train, the driver of the MTM train and eight passengers on the MTM train sustained minor injuries in the incident.
What the ATSB found
The ATSB found that the operating rule permitted the V/Line train to proceed past a signal at Stop into a section that was occupied by the MTM train. The V/Line train was operated past the signal at Stop in a manner contrary to the operating rule and proceeded at a speed that reduced the opportunity to observe the train ahead and stop in time. The rule placed reliance on the train driver to provide separation between trains by line-of-sight observation and was not an effective defence against errors.
The ATSB also found that the marker lights on the MTM train (Comeng type) did not meet the requirements of the Australian Standard for Railway Rolling Stock Lighting and Rolling Stock Visibility, AS/RISSB 7531.3:2007 for permissive working[3]. This standard was developed by the Rail Industry Safety Standards Board (RISSB) and although MTM had adopted this Standard, it was not implemented on the Comeng trains in their fleet.
What's been done as a result
Metro Trains Melbourne has amended the existing procedure in Section 3 Rule 1 of The Book of Rules and Operating Procedures 1994 for permitting trains to pass an uncontrolled, unmonitored signal at Stop. The new amendments incorporate a procedure, which requires train drivers to contact and respond to an automated voicemail facility providing their details, the rail vehicle details and details of the signal at Stop.
Metro Trains Melbourne has advised the ATSB that a modification is being developed to increase the intensity of the marker lights of Comeng trains to a level compliant with the Australian Standard for Railway Rolling Stock Lighting and Rolling Stock Visibility, AS/RISSB 7531.3:2007.
Safety message
The rules pertaining to permissive signalling rely on a train driver to provide separation between trains by line-of-sight observation. In the hierarchy of hazard controls, rule based controls are considered the least effective defence against human error or violations. Train operators should institute additional risk mitigation measures, where safeworking systems allow permissive working.
The safety issues identified during this investigation are listed in the Findings and Safety issues and actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.
All of the directly involved parties were provided with a draft report and invited to provide submissions. As part of that process, each organisation was asked to communicate what safety actions, if any, they had carried out or were planning to carry out in relation to each safety issue relevant to their organisation.
The initial public version of these safety issues and actions are repeated separately on the ATSB website to facilitate monitoring by interested parties. Where relevant the safety issues and actions will be updated on the ATSB website as information comes to hand.
Permissive Signalling System
The rules pertaining to passing a permissive signal at stop, place sole reliance on the train driver to provide separation between trains by line-of-sight observation. In the absence of any additional risk mitigation measures, this administrative control provides the least effective defence against human error or violations.
The marker lights on some MTM passenger trains do not meet the requirements of the standard for Railway Rolling Stock Lighting and Rolling Stock Visibility, AS/RISSB 7531.3:2007.
The sources of information during the investigation included:
Metro Trains Melbourne
V/Line Pty Ltd
Metro Trains Melbourne Train Driver
V/Line Train Driver.
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, US Federal Aviation Administration.
Cheyne, J.A., Soman, G.J.F., Carriere, J.S.A., and Smilek, D. (2008). Anatomy of an error: A bidirectional state model of task engagement/disengagement and attention-related errors. Cognition, 111, 98-113.
Dawson, D. & McCulloch, K. (2005). Managing fatigue: It’s about sleep. Sleep Medicine Reviews, 9, 365-380.
Regan, M.A., Hallett, C., and Gordon, C.P. (2011). Driver distraction and driver inattention: Definition, relationship and taxonomy. Accident Analysis and Prevention, 43, 1771-1781.
Smallwood, J. & Schooler, J.W. (2006). The Restless Mind. Psychological Bulletin, 132 (6), 946-958.
Thomas, MJW. & Ferguson, SA. (2010). Prior sleep, prior wake, and crew performance during normal flight operations. Aviation, Space, and Environmental Medicine, 81 (7), 665-670.
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 V/Line, Metro Trains Melbourne, Public Transport Victoria, Transport Safety Victoria, Office of the National Rail Safety Regulator and the train drivers.
Submissions were received from V/Line, Metro Trains Melbourne, Public Transport Victoria, Transport Safety Victoria and the Office of the National Rail Safety Regulator. The submissions were reviewed and where considered appropriate, the text of the draft report was amended accordingly.
Safety analysis
Unintended stop of Comeng train
The Comeng train’s data recorder indicated a sudden loss of brake pipe air pressure at about 18:55. At the same time, the data recorder indicated an instantaneous rise (a spike) in the lateral acceleration graph of car 484M. Visual inspection and testing of the train revealed that the brake pipe of car 427M was damaged and the suspension airbag on car 487M was leaking. The cause of the damage to these two cars and the sudden loss of brake pipe pressure could not be determined.
Permissive signalling systems
Section 3 Rule1 facilitates the flow of rail traffic on the network under certain circumstances by permitting trains to pass an uncontrolled, unmonitored signal, enter a section which may or may not be occupied by another train that is not immediately observable, or enter an unoccupied section where some infrastructure condition may be affecting the signal’s operation.
There are 925 automatic signals on the Melbourne metropolitan train network. A driver may be required to stop and proceed at any of these Automatic signals for any of the above reasons. On average, the provisions of Section 3 Rule 1 are applied about 35 times a day at these automatic signals, before proceeding past them at Stop.
Although permissive signalling is used in other jurisdictions in Australia and overseas, the Stop and Proceed Rules in these jurisdictions are more rigorous in that they permit drivers to proceed past an automatic signal at Stop only if they are unable to contact a signaler and under conditions specified in the rule.
In Victoria, the Rule does not require a driver to report that they are intending to pass an Automatic signal at Stop. Further, there is no monitoring of compliance with the Rule when a train passes an automatic signal at Stop. However, the system requires drivers to advise the train controller the reasons for not passing an automatic signal at Stop.
Since 1982 there have been seven collisions involving trains that have stopped and proceeded past automatic signals at Stop. These incidents resulted in changes to radio communication methods and minor changes to the Stop and Proceed Rule. Despite these changes, the Stop and Proceed Rule still relies on a train driver to provide separation between trains by line-of-sight observation. Considering the hierarchy of controls[19], administrative or rule based controls are low on the hierarchy and is considered the least effective defence against human error or violations.
Actions of the train driver and situational factors
Compliance with rule at and after passing signal GG630
After arriving at signal GG630, the V/Line train stopped at this signal for about three seconds before resuming its journey. The rule required drivers to stand at an Automatic signal at Stop for a minimum of 30 seconds and then travel at a speed not exceeding 25 km/h. The train reached a speed of 43 km/h before colliding with the stationary MTM train. This reduced the opportunity to observe the train ahead and stop in time.
Driver attention and distraction
Cognitive workload
The driver was familiar with the line and route. He was familiar with the operation of the VLocity train and the tasks required of him. There was no compelling evidence to suggest that the driver’s cognitive workload impeded the performance of his train driving tasks.
Fatigue
In the context of human performance, fatigue is a physical and psychological condition which can arise from a number of different sources, including time on task, time awake, acute and chronic sleep debt, and circadian disruption (disruption to normal 24-hour cycle of body functioning). 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.[20] Fatigue impairment has been identified as contributory in a significant number of rail accidents and incidents. Research has indicated that anything less than 5-6 hours sleep in 24 hours and 12 hours sleep in 48 hours is likely to lead to fatigue impaired performance.[21][22]
The train driver’s roster indicated that he had been on afternoon shift for the previous fortnight. The driver indicated that his previous three shifts were ‘standby’ shifts and that the workload was light. On the day of the incident he was rostered to and signed on at about 1300. He travelled as a passenger on the 1320 Geelong train. In Geelong, he prepared a locomotive and then completed a run-around to Marshall and returned to Geelong. He was then assigned to take the 8246 empty service to Southern Cross Station, Melbourne.
Based on the evidence provided to the ATSB, the driver of the train obtained about 7-8 hours of sleep in the 24 hours leading up to the occurrence and about 16-18 hours of sleep in the 48 hours prior. There was no evidence to suggest that the quality of the driver’s sleep in the preceding days had been compromised. Further, the sleep opportunity periods provided while driving the afternoon shift had significant overlap with the circadian trough (around 0200 to 0600), when sleep is generally at its most restorative.
Considering all of the available evidence concerning quantity and quality of sleep obtained and reported alertness on duty, the driver’s cognitive performance was likely to have been at a manageable level at the time of the event. The available evidence did not support a contention of fatigue impairment as contributory to this accident.
Expectancy
The V/Line driver reported that typically, he followed the train ahead and adjusted his speed in order to ensure that the train had cleared the block before he approached the signal. This was to ensure that the signal changed to Caution (Yellow) when he approached it and he could proceed past the signal without stopping. He stated that the EMU should have been ‘gone’ from the section and did not expect it to be in the section. Further, the driver advised that he had encountered automatic signals at Stop before and had stopped and proceeded past the signal without encountering another train in the section ahead. It is unlikely that the driver would have operated the train in the manner he did, had he expected the track section to be occupied.
Driver distraction
Distraction can be understood as a type of inattention, where a person’s attention is diverted by a particular event or object. Potential sources of distraction for the train driver included his mobile phone and two-way radio in the cab. There was no evidence to indicate that the driver was operating or otherwise attending to any of this equipment on passing signal GG630.
The driver stated that the lights and noise from the refinery distracted him. Although the refinery is about three kilometres from the location of signal GG630, it is possible that the flame from the refinery’s flare stack may have distracted the driver.
Attentional disengagement (mind wandering)
While driver distraction is widely acknowledged as impeding performance of driving tasks, it is important to recognise that people can also become unintentionally inattentive to driving tasks without the presence of a competing activity.[23] Attentional disengagement, or mind wandering, can be described as occurring when attention normally directed toward the primary task momentarily shifts away from the external environment, even though the individual continues to show well practiced automatic responding.[24][25] Mind wandering or ‘zoning out’ can occur in situations where tasks are protracted, unvarying, familiar, repetitive or undemanding.[26] It is therefore possible that the driver’s mind wandered and that his focus was not on the driving tasks and he did not observe the Comeng train ahead of him until it was too late.
Train marker lights
The Board of Inquiry into the incident near Aircraft Station in Victoria in 1998, made several recommendations with respect to end of train marker lights:
End of Train Markers (ETM) should denote the rear vehicle of a train to the driver of a following train during darkness and especially during inclement weather.
That a standard be developed for marker lights that allows viewing by the driver of a following train, as well as by signalling staff and others to ascertain a train is complete.
That a study be undertaken to assess the viewability of marker lights currently in use on all trains during inclement weather.
That a defined procedure for checking the viewability of ETMs and (if not already in place) other tail signals be adopted.
A standard for ETMs was first developed 2007 and the current version of the standard AS/RISSB 7531.3:2007 recommends that rolling stock operating in a network where the Safeworking System allows Permissive Working then each tail light shall have a luminous intensity of at least 100 candela (100 lux at one metre). The other recommendations by the board have not been implemented or carried out by subsequent train operators.
Tests carried out on the type of marker lights used on the Comeng and Siemens trains indicated a luminosity of 33 Lux at one metre and a luminosity of 30 Lux at one metre, both below the value recommended by the Standard. After the incident, Comeng train tail light sighting tests were conducted at night, in the incident site. An observer noted that the marker lights tended to disappear at night due to the refinery lighting and the LED signals. Low luminosity marker lights may not be discernible in areas of other illuminations. Although MTM had adopted the AS/RISSB Standard, they have not implemented it on their rail fleet.
Considering the above, it would be appropriate for MTM to institute measures to ensure that the luminous intensity of marker lights of all passenger trains in their fleet meet a railway industry approved and accepted standard.
At about 1840[4] on 22 August 2014, Metro Trains Melbourne (MTM) passenger train 6502 departed Werribee Railway Station on its scheduled service to Flinders Street Station. The train arrived at Laverton Railway Station at about 1852 without incident.
Figure 1: Location map – Showing train line from Werribee to Melbourne and location of collision
Source: Copyright Melway Publishing 2013, Edition 41 with annotations by the Chief Investigator, Transport Safety (Victoria)
The train departed Laverton Railway Station and all signal aspects from Laverton were at clear normal speed (Green over Red). At about 1855, the train achieved a maximum speed of 115 km/h — the maximum authorised line speed for this section of track. Shortly after passing signal GG630 (Figure 2) and when near Cherry Creek, the driver heard a ‘loud bang’ from under the train. He noted that the brake pipe pressure had decreased and the brake cylinder pressure had increased. There was an immediate reduction in speed and the driver placed the brake handle to the full service braking position. When the train came to a stop, he placed the Reverser to the off position, which automatically applied the park brake. The train came to a stop at 1855, with the rearmost car, 427M, at about the 16.53 rail km mark[5].
The driver looked back and concluded that the train had not derailed and that it was not fouling the adjacent running lines. He called Metrol[6] to advise them of the location of the train and that the train had lost brake pipe pressure. He then made an announcement on the public address system to the passengers to advise them that the train would be delayed due to a defect. The driver then called Metrol for authority to go on the track to conduct an inspection of the train.
Figure 2: Collision location and signals
Source: Metro Trains Melbourne with annotations by the Chief Investigator, Transport Safety (Victoria)
Figure 3: Signal GG630 and indication of collision site
Source: Chief Investigator, Transport Safety (Victoria)
V/Line Service 8280
At about 1802 on the same evening, V/Line train 8280 departed Geelong for Southern Cross Railway Station. The train was returning to Southern Cross in preparation for a scheduled passenger service, and was crewed by a driver and a conductor but carried no passengers. At about 1832, the train came to a stand at Automatic signal GG1178 (between Little River and Werribee) which was at Stop and resumed its journey about 17 seconds later. After passing through Laverton Station, it proceeded at about 90 km/h past Automatic signal GG672 that was indicating a normal speed warning (Yellow over Red). The train then arrived at Automatic signal GG630 that was indicating a Stop aspect (Red over Red). This signal was at Stop as train 6502 had not cleared the block ahead. Train 8280 stopped at signal GG630 for about three seconds before resuming its journey. Trains can proceed past an Automatic signal at Stop under conditions specified by a rule in The Book of Rules and Operating Procedures 1994.
The collision and post collision events
After passing signal GG630, the V/Line train reached a speed of 43 km/h and collided at this speed with the rear of the stationary MTM service 6502 at about 1901. The MTM train had been stopped for about 6 minutes, before the collision. The data logger of the V/Line train indicated that emergency braking was applied by the driver 1.4 seconds before the collision.
The MTM train was shunted about 30 m due to the impact and the impacted cars stopped at about the 16.5 rail km mark, approximately 1210 m from signal GG630. The driver of the MTM train was thrown onto the cab floor by the impact. The V/Line driver was trapped between the train control console and the seat but managed to extricate himself by lowering the seat. He got out of his cab, walked towards the MTM train and spoke to passengers on the train to inquire as to their wellbeing and then spoke to the MTM driver who was still in the cab of his train.
MTM staff detrained the 51 passengers and escorted them to service replacement buses. The driver and conductor on the V/Line train, the driver of the MTM train and eight passengers from the MTM train sustained minor injuries in the incident. Both trains were significantly damaged (Figure 5).
Figure 4: Impacted trains
Source: Chief Investigator, Transport Safety (Victoria)
Figure 5: Train damage
Source: Chief Investigator, Transport Safety (Victoria)
The following findings are made with respect to the collision between a Metro Trains Melbourne passenger train 6502 and V/Line train 8280 between Maidstone Street level crossing and Kororoit Creek Road in Altona, Victoria. 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
Comeng train 6502 stopped unexpectedly in the section.
The rules pertaining to passing a permissive signal at stop place sole reliance on the train driver to provide separation between trains by line-of-sight observation. In the absence of any additional risk mitigation measures, this administrative control provides the least effective defence against human error or violations. [Safety issue]
The V/Line train passed automatic signal GG630 at the Stop position in a manner contrary to the operating rule and proceeded at a speed that reduced the opportunity to observe the train ahead and stop in time.
The V/Line train driver did not observe the Comeng train ahead probably due to being distracted or disengaged from his driving tasks.
Other factors that increased risk
The marker lights on the Comeng train did not meet the requirements of the standard for Railway Rolling Stock Lighting and Rolling Stock Visibility, AS/RISSB 7531.3:2007. [Safety issue]
Context
Location
The collision occurred on the MTM rail network between the Maidstone Street and Kororoit Creek Road level crossings in Altona, Victoria (Figure 6). Altona is approximately 22 km from Flinders Street Station, Melbourne.
Figure 6: Location of collision
Source: PASS Assets (Public Transport Victoria) with annotations by Chief Investigator, Transport Safety
Track and environmental conditions
The track infrastructure in this section consisted of a Broad Gauge East Line, a West Line and an independent parallel Standard Gauge line (Figure 2). Both trains were operating on the West Line. From the Maidstone Street level crossing, the track has a slight uphill gradient towards Cherry Creek. Clear sighting is available up to Cherry Creek from the Maidstone Street level crossing. The weather conditions were fine and it was a clear night with light winds.
Suburban train 6502
Train 6502 was of the Comeng type and consisted of two, 3-car sets, in a Motor (M) - Trailer (T) - Motor (M) three-car configuration. This train consisted of cars 338M - 1092T - 484M and 487M - 1052T - 427M. Comeng type Electrical Multiple Units (EMU) are single deck stainless steel car body trains, built by Commonwealth Engineering (Comeng) Dandenong, Victoria between 1982 and 1989.
Figure 7: Train 6502 configuration
Source: Chief Investigator Transport Safety, Victoria
MTM train crew
The MTM driver at the time of the incident had about 2½ years train driving experience. He held the required qualifications to operate the train, was route certified and assessed as medically fit for duty. Following the collision, the MTM train driver underwent mandatory drug and alcohol testing, returning a zero result.
Unintended stop of Comeng train
The train’s data recorder indicated that the brake application was not driver initiated or a vigilance[7] brake application. The evidence also did not indicate that the braking was a result of the activation of the trip lever[8]. The Comeng train was inspected after the collision, with particular attention to the braking system. Visual inspection and testing of the first three units 338M-1092T-484M did not reveal any damage to the brake pipes or the reservoirs. Inspection of the next three cars 487M-1052T-427M, revealed that the brake pipe of 427M was damaged and the suspension airbag on 487M was found to be leaking. The cause of the damage to these two cars could not be determined with certainty due to the impact damage.
Comeng train marker lights
Comeng train marker lights are located above the drivers cab windscreens and consist of an outer white light and an inner red light. The white light when illuminated indicates the front of the train, while the red light when illuminated indicates the rear of the train.
Figure 8 - Comeng train lights
Source: Chief Investigator, Transport Safety (Victoria)
Post incident inspection and testing indicated that the train’s rear marker lights were operational. Analysis of CCTV footage of this train passing Laverton Railway Station also showed that the marker lights were on at the time of passing this station.
Rollingstock lighting standards
The Rail Industry Safety and Standards Board (RISSB) is owned by its funding members that include Commonwealth, State and Territory governments and Rail Transport Operators in Australia. RISSB develops and manages rail industry standards, rules, codes of practice and guidelines.
In 2007, RISSB published a standard for Railway Rolling Stock Lighting and Rolling Stock Visibility, AS 7531.3:2007 (AS/RISSB 7531:3:2007). The RISSB standard is not prescribed, but some operators including MTM have adopted this Standard. The standard states ‘If operating in a network where the Safeworking System allows Permissive Working then each tail light shall have a luminous intensity of at least 100 candela’.
Luminous intensity testing of marker lights
The luminous intensity of a new marker light (new lens, retro reflective sheeting and lamp) of the type fitted to Comeng trains was measured. An approximate luminosity reading of 33 Lux at one metre[9] was recorded. In comparison, MTM advised that the approximate luminosity of the Siemens train marker light was 30 Lux at one metre and the X’Trapolis train marker light was 200 Lux at 1 meter.
V/Line Service 8280
The V/Line train 8280 was a VLocity Diesel Multiple Unit consisting of VL05 (units 1105 and 1205), VL12 (units 1112 and 1212) and VL39 (units 1139, 1339 and 1239).
Figure 9: Train 8280 DMU configuration
Source: Chief Investigator Transport Safety, Victoria
Post incident testing indicated that the train’s headlights were operational and the train’s data logger indicated that the train’s headlights were on at the time of the incident.
V/Line train crew
The V/Line train had two crewmembers, a driver and a conductor. The driver had been driving trains since qualifying in 1989 and was employed as a train driver by V/Line for the last 11 years. He held the required qualifications to operate the train, was route certified and assessed as medically fit for duty.
Control console
The driving control console of the VLocity is a wrap-around style instrument panel (Figure 10). The cab windows provide good visibility for the train driver. The Reverser is a four-position switch that is moved between Off, Forward, Neutral and Reverse positons. The Power/Brake Controller (PBC) is used to control traction power and brake effort. The PBC operates in power mode when pulled back from the centre ‘off’ position and in the brake mode when pushed forward from the centre position. There are six power notches that dictate the tractive effort. In brake mode, the controller moves seamlessly between minimum and full service braking. The Secondary Brake Controller (SBC) is used in the event of a brake control unit failure and braking effort becomes unavailable through the PBC. The SBC directly controls the brake pipe pressure to independently apply and release the brakes. Emergency braking can also be achieved by activating the emergency brake pushbutton located on the control console.
Figure 10 - Driver control console showing the main controls
Crashworthiness performance of the trains
Both trains were designed for the possibility of a limited speed collision with another train or obstruction. Train body structures and fittings were designed to accommodate significant loads and each train included special crashworthiness features to absorb collision energy. Such features aimed to reduce injury to passengers and train crew, particularly in low to medium speed collisions.
Crashworthiness design features of the VLocity included:
energy absorption within multi-function couplers at #1 (driver cab) ends
energy absorption within semi-permanent couplers at #2 (non-driver) ends
shear-off plates at multi-function couplers
anti-climbers at both #1 and #2 ends
an energy absorbing structure protecting the driver’s cab.
Crashworthiness design features of the Comeng included:
energy absorption within multi-function couplers at #1 (driver cab) ends
energy absorption within semi-permanent couplers at #2 (non-driver) ends
anti-collision posts at both #1 and #2 ends.
The collision speed of 43 km/h exceeded the design capacity of several of the energy absorbing features. Nonetheless, many of the features performed as would be expected, absorbing energy and providing a level of protection to passengers and train crew. In particular, the energy absorbing structure protecting the driving position deformed as designed when the VLocity impacted the rear end of the stationary Comeng train.
VLocity car-to-car crashworthiness features performed as expected, with the following exceptions:
The shear off plates on the leading coupler functioned in advance of any significant absorption within the coupler itself.
The leading coupler of the second car set (car 1112) did not absorb energy as might have been expected in an end-to-end collision.
Anti-climbers between the lead and second car sets (between cars 1205 and 1112) have engaged but then distorted leading to some override by car 1205. Probably as a result of this climb, some members and connections within the structure protecting the cab have failed in advance of full absorption of collision energy. In turn, there was significant encroachment of the cab of car 1112.
Comeng car-to-car crashworthiness features performed largely as expected. Coupler energy absorption features functioned and car end collision posts remained intact.
The car body structures of both trains generally withstood the collision loading with some minor structural incursions at car ends. As a result, the level of damage within the passenger envelopes was not significant. In addition, on both trains there was only a small amount of equipment dislodgement within the passenger compartments.
Signalling system
A three-position colour light signalling system is in place between Laverton and Newport, and consisted of Home (Absolute) and Automatic signals (Permissive). Three position signals provide information to drivers regarding the compliance speed for the block[10] and information on the aspect of the signal ahead.
Home signals are controlled by a signaller or train controller. Home signals are Absolute signals and are not to be passed when displaying a Stop aspect unless written or verbal authority is provided as specified in the Book of Rules and Operating Procedures 1994.
An automatic signal is not directly controlled by a signaller or train controller but by the passage of trains detected by track circuits. Their function is to provide separation between trains travelling in the same direction on the same track in accordance with the line speed and headway requirements of that section of track.
When the track ahead is unoccupied, an Automatic signal will be at Proceed. In the MTM managed Melbourne Metropolitan Network the Safeworking System allows Permissive Working.
Permissive signalling
Historically permissive signalling systems were adopted to allow following train movements between controlled locations predominantly through areas where there were no communications. Permission to pass an automatic signal at Stop was provided in the form of a rule, to allow train movements to continue, under prescribed conditions, when a signaller could not be contacted.
Victoria
In Victoria, permissive signalling has been in operation since the introduction of 3-position signalling in 1915. There have been several changes to the rule pertaining to permissive signalling since its introduction. In the MTM managed Melbourne Metropolitan Network, the safeworking system allows Permissive Working.[11]
The current rule pertaining to permissive signalling is specified in Section 3 Rule 1 of The Book of Rules and Operating Procedures 1994.[12] This rule is also specified in the ARTC Code of Practice for the Victorian Main Line Operations, Section 3 (Rule TA 20). The rule extracted in part states that:
‘The Driver must bring the train to a stand for 30 seconds if an automatic signal displays ‘Stop’. If the automatic signal is still at ‘Stop’ after 30 seconds, the Driver may proceed, but must control the speed of the train at extreme caution, being prepared to find the section ahead occupied or obstructed, or the track damaged’.
The rule further states that:
‘Extreme caution is defined as being able to stop the train in half the distance that can be seen ahead; not exceeding 25 km/h or the posted track speed if that is the lesser, and always being prepared to find the section ahead occupied or obstructed, or the track damaged. Except where special instructions are issued to the contrary or where a disabled train requires assistance, a Driver must not pass any signal when it is known there is a train in the section’.
New South Wales
In New South Wales (NSW), the operating rule pertaining to permissive signalling systems is specified in the ARTC Operating Rule ANSG 608. The rule extracted in part states that:
If a Driver can see that the block ahead is obstructed, they must speak to the Signaller before passing an automatic signal at STOP.
If the whole of the block ahead cannot be seen, a Driver must try to speak to the Signaller before passing an automatic signal at STOP.
If the Driver is unable to speak to the Signaller, they may pass the signal at STOP.
A Driver may pass an automatic signal at STOP without speaking to the Signaller, if the Driver can see that the whole block ahead to the next signal is unobstructed.
As soon as practicable, the Driver must report to the Signaller at the next attended location:
the number or designation of the signal passed at STOP, and
the condition of the line.
At any time, the Signaller may tell the Driver not to pass the signal at STOP. In all cases, the Driver must record, in permanent form, the time and the signal number or designation of the signal passed at STOP.
Western Australia
In Western Australia, Automatic Signals are referred to as Approach Signals as they are situated on the approach side of a home signal.
The network rule for passing an Approach Signal states that:
The driver of a train stopped at a red Approach signal must contact the Train Controller and state:
train number and description,
signal number and section.
The Train Controller must then instruct the Driver to remain at the signal or pass the signal at Stop.
Where a Driver is instructed to pass the Approach signal at Stop, the Driver must proceed cautiously, prepared to find the line obstructed, or a broken or displaced rail.
If the Driver is unable to contact the Train Controller the Driver must wait one minute then pass the signal, proceeding cautiously, prepared to find the line obstructed, or a broken or displaced rail.
Monitoring trains on the network
Metropolitan Train Control Centre (Metrol) is the control centre for Melbourne's suburban rail network. Metrol has the ability to directly monitor approximately 43 per cent of the electrified metropolitan train network.
Signallers and train controllers located at Metrol directly control all train movements in the inner core of the suburban system including the operation of points and signals. Outside the suburban inner core, the movement of points and signals is carried out from remote signal boxes in consultation with Metrol.
Each signaller monitors a visual display unit indicating signals and points and there are five display units for Caulfield, Western, Northern, Burnley and Clifton Hill regions. The role of the signallers is to monitor the movement of trains, signals and points, and route trains as required.
Train drivers are required to contact signallers to clarify operational requirements, report faults or operational breaches.
There are three train control workstations and a radio operator’s workstation, each staffed by a signaller. The radio operator receives verbal information relayed to them by train drivers, station staff and signallers at the remote sites. The role of these signallers is to convey information received to the Metrol shift supervisor and other relevant personnel or fault rectification centres.
A portion of the metropolitan train network, including the incident area (Laverton), is currently not directly monitored by Metrol and is controlled and partially monitored from signal boxes located at remote sites. The incident area was controlled from the Newport signal box. The display unit at Newport does not provide specific information on the location of trains. In general, the signalling and station staff located at remote signal boxes will only contact Metrol when there is new information or an incident.
Compliance monitoring of Section 3 Rule 1
On the Melbourne Metropolitan Network, MTM has the dual role of the network manager and a train operator. MTM train drivers are subjected to regular safety audits but there is no specific network monitoring processes in place to measure compliance with Section 3 Rule 1. MTM does not monitor V/Line trains for compliance with the rule on their network.
From May 2015, MTM instituted an automated voicemail system, where train drivers on the metropolitan network are required to call on the system when they encounter an automatic signal at Stop and proceed past the signal as allowed by Section 3 Rule 1. Based on the voicemail data from 01 July 2015 to 31 December 2015, MTM and V/Line trains stopped and proceeded past automatic signals about 35 times per day.
Train communication
When a suburban train driver needed to contact Metrol, the driver was required to log a call to Metrol using the train’s radio system, the Urban Train Radio System[13] (UTRS). Once a call was logged, the driver had to wait for Metrol to respond. If the driver deemed the situation to be an emergency, they could contact Metrol using the emergency call button on the radio system or use their company-issued mobile phone. V/Line trains operating on the Melbourne metropolitan network cannot contact Metrol directly. They have to call Centrol[14] who contact Metrol to convey any information on V/Line train operations. Similarly, Metrol cannot contact V/Line trains and have to convey any information regarding their trains and network to Centrol, who convey that information to V/Line trains.
In this instance, the MTM driver did not consider the situation to be an emergency, hence waited for Metrol to call him after logging a call on the train’s radio system. While waiting for Metrol to respond, he contacted his supervisor on his mobile phone to discuss the mechanical defect that caused the Comeng train to come to a stop. After speaking to his supervisor, he called Metrol on his mobile phone and managed to get through to Metrol. During his mobile phone call with Metrol, Metrol called him on the train radio system, and he advised Metrol that he was already speaking to a controller on his mobile phone. During his conversation with Metrol, the V/Line train collided with the Comeng train.
Signal operation data logging
Laverton and Altona Junction utilises Computer Based Interlocking (CBI-SSI)[15]. The system provides safety interlocking between points, signals and train movements and a data logging facility.
The block section between Laverton and Altona Junction is indicated on the Laverton Data logging Facility as well as the Newport Logging Facility.
The area where the incident occurred is between these two locations and limited information is available from the incident area. The available data indicates that the Maidstone Street level crossing and the signals in the block section between Altona Junction and Laverton were operating satisfactorily. No signal aspect information is logged in the area between LAV732 and ALJ232; hence, there was no signal aspect information for Signal GG630. However, post incident testing of Signal GG630 indicated that the signal was functioning as required.
Previous occurrences associated with permissive signalling
There have been several incidents associated with Automatic signals and the application of the ‘Stop and Proceed’ rules.
On 17 June 1982, an Up[16] standard gauge freight train collided with rear of the Up Interstate passenger train Spirit of Progress at Barnawartha, Victoria. The freight train had passed the previous automatic signal at Stop as permitted by Regulation 74[17]. At the time of the incident, the passenger train was stationary due to a defective locomotive and there was heavy fog in the area. The driver and fireman operating the freight train were fatally injured and 20 passengers on the Spirit of Progress suffered injuries. Because of this incident, radio communications between the network control centre and locomotive drivers and the locomotive driver and train guard were introduced on the intrastate network.
On 8 October 1986, an Up freight train collided with the rear of another freight train, which was stationary at a Home signal waiting entry into the South Dynon yards in Victoria. The previous automatic signal was passed at Stop as permitted by Regulation 74. Visibility was restricted by track curvature. As a result of this incident, the Automatic signal involved was converted to a Home signal.
On 16 October 1989, a suburban passenger train collided with the rear of another suburban train, which was stationary at a Home signal at Ringwood in Victoria. The driver had passed the previous automatic signal as permitted by Regulation 74. Twenty-one passengers were injured in the collision. Because of this incident, the application of Regulation 74 was reinforced with train drivers.
On 20 November 1989, a suburban passenger train collided with the rear of another suburban passenger train, which was stationary at the Syndal Station platform in Victoria. The driver had passed the previous automatic signal as permitted by Regulation 74. The collision resulted in injury to 75 persons. Because of this incident, the application of Regulation 74 was reinforced with train drivers.
On 27 July 1998 a suburban passenger train collided with the rear of a stationary freight train near Aircraft Railway Station in Laverton, Victoria. Weather conditions at the time resulted in a limited viewing distance. At this time, Section 3 Rule 1 in the Victorian Book of Rules and Operating Procedures 1994 had superseded Regulation 74 (). Because of this incident, the application of Section 3 Rule 1 was reinforced with train drivers.
On 2 December 1999, an inter-urban train collided with the rear wagon of the Indian Pacific train at Glenbrook, New South Wales. The Indian Pacific train was stopped at an automatic signal displaying a Stop aspect. The driver of the inter urban train, on arriving at the previous automatic signal also displaying a Stop aspect, sought authority from a signaller to pass the signal. Once he received the authorisation he proceeded at a speed contrary to the relevant operating rule. On observing the rear wagon of the Indian Pacific train, the driver made an emergency brake application, but was unable to stop in time and collided with Indian Pacific train. The main recommendation from the inquiry into this incident was that the NSW Government should establish two separate independent authorities for regulating rail operations (Rail Safety Inspectorate) and investigating rail accidents (Rail Accident Investigation Board).
On 26 July 2000, a suburban express passenger train collided with the rear of another suburban passenger train that was stationary at the Holmesglen Station platform. The incident resulted in severe damage to both trains and 12 persons sustained injuries. Because of this incident, Section 3 Rule 1 was amended to include a mandatory maximum speed of 25 km/h after an automatic signal had been passed at Stop.
A report (dated May 2001) produced by the then Department of Infrastructure’s Office of the Director of Public Transport, Safety and Technical Services Branch recommended that the train operator assess the benefits and practicality of installing speed limiting equipment (after passing signals at danger) and data loggers to suburban trains. The train operator Connex assessed the benefits and practicality of installing the speed limiting technology but did not adopt it due to the perceived impacts on time performance, the limited effectiveness of the equipment and the complexity and costs involved.
On a Flinders Street to Craigieburn Metro Trains Melbourne suburban train, travelling on the Down[18] broad gauge line, ran into the rear wagon of a stationary Pacific National freight train between Roxburgh Park and Craigieburn stations in Victoria. At the time, the freight train was stopped at a signal. The investigation conducted by the Chief Investigator, Transport Safety, determined that the driver of the suburban train had passed two automatic signals after departing Roxburgh Park that presented a stop aspect. When passing the signals the driver did not comply with the network Rules and operating procedures. The investigation made recommendations with respect to the network’s ability to monitor the application of and compliance to Section 3 Rule 1 of the Book of Rules and Operating Procedures 1994, train speed limiting devices after passing signals at stop and the acceptance and application of industry standards for train tail signals.
In response to the Craigieburn incident Public Transport Safety Victoria (PTSV) now Transport Safety Victoria (TSV) issued a safety alert requesting transport providers and managers of rail infrastructure and rolling stock review the procedure and drivers compliance with the procedure for passing an automatic signal at stop. MTM carried out a review of Section 3 Rule 1 of the Book of Rules and Operating Procedures 1994 and concluded that no change was required to the Rule. Further, they reported that driver compliance monitoring was being carried out during the driver audit process. MTM also reported that they intended investigating the practicality of implementing speed limiting of trains when passing an Automatic signal at Stop and had adopted the standard Railway Rolling Stock Lighting and Rolling Stock Visibility, AS 7531.3:2007.
A recent example of an overseas incident was when a passenger train collided with a train that was stabled at a platform at Norwich station in the United Kingdom on 21 July 2013. Permissive working was authorised in the signal section of the station, hence the passenger train was authorised to proceed past a signal at Stop. The driver of the passenger train was aware that a train was stabled at the platform, and observed this train, when he made a brake application. The Rail Accident Investigation Board (RAIB) identified that the driver had either a lapse of concentration or a microsleep. The RAIB recommended that the rail operator review its audit procedures and non-compliance with their operational procedures, driver training, driver fatigue management and conduct a risk assessment of permissive working.
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
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On 4 October 2011, the container ship Rena departed Napier, New Zealand, bound for Tauranga, New Zealand, with an estimated arrival time of 0300 on 5 October. At about 0214 on 5 October, Rena grounded on Astrolabe Reef.
The Transport Accident Commission (TAIC) of New Zealand is undertaking a formal investigation into this accident. As part of that work, TAIC requested the assistance of human factors specialists at the Australian Transport Safety Bureau (ATSB), to assess the likelihood and extent of any performance impairment to the master and second mate due to fatigue. To protect the information supplied by TAIC, the ATSB initiated an investigation under the provisions of the Transport Safety Investigation Act (2003).
Following the analysis of the sleep and work data supplied by the TAIC, the ATSB conducted analysis of the fatigue likelihood and produced a report which was provided to TAIC on 26 August 2014. For further information on this occurrence and investigation, please contact the Transport Accident Investigation Commission of New Zealand.
