What happened

On 29 October 2013, the Australian Rail Track Corporation (ARTC) was undertaking a program of ballast remediation and drainage maintenance on the bidirectional west track between Benalla and Wangaratta, Victoria. This required Absolute Occupation of the west track and Track Force Protection on the east track due to the proximity of the track workers and their machinery. Worksite protection was put in place at 0644, which involved placing flagmen and Audible Track Warning signals (ATWs) either side of the worksite.

The worksite at Glenrowan used two radio channels for communications. One channel was used for safety critical communication between the flagmen and the track force coordinator, the second was used for worksite communication between the track workers, including the track force coordinator. The track workers relied on the track force coordinator for safety critical communication since they had no direct communication with the flagmen.

At approximately 0730, V/Line passenger train 8610, travelling between Albury and Melbourne on the east track, stopped at Wangaratta to pick up passengers. The track force coordinator at Glenrowan was made aware of the train by the flagmen on the west track. The track force coordinator then instructed the flagmen on the east track to remove the ATWs and allow the train to pass the work site unrestricted. This was done without informing the work site supervisor or any of the track workers.

At about 0744, the outer flagman observed train 8610 and contacted the inner flagman to let her know that the train was approaching. The inner flagman attempted to contact the track force coordinator multiple times, but did not get a response. The track force coordinator was in conversation with the work site supervisor and not within earshot of either of his radios. The inner flagman then tried to alert the track force coordinator by whistle without success.

At about the same time, the work site supervisor observed train 8610 approaching and called out ‘Train on’ on the work site radio. The track workers also saw the train and took action to ensure that they and their machines were clear of the east track. The driver of Train 8610 did not notice anything unusual as the train passed through the worksite (without incident) at about 0746.

After the incident, the work site supervisor took control of the site and, following an on-site assessment of the incident, called a halt to the works at Glenrowan. At 0900, the track force coordinator contacted the network controller to advise there had been an incident and that track protection on the east track at Glenrowan was lifted until further notice. The track force coordinator contacted the network controller again at 1030 to report the details of the near-miss incident at Glenrowan between track workers and train 8610.

The track force coordinator was tested for the presence of alcohol or other drugs which proved negative.

Safety action

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

Australian Rail Track Corporation

As a result of this occurrence, the Australian Rail Track Corporation has advised the ATSB that they are taking the following safety actions:

• A post-incident meeting was held with all BRP personnel to discuss the incident and reinforce the necessity to follow procedures when providing track protection.
• The program manager instructed all site personnel that ATWs were to be left on track to warn of trains approaching worksites.
• Follow up training and recertification was provided regarding the relevant network safeworking rules.

Safety summary

What happened

On 3 October 2013, immediately before HC Rubina sailed from Beira, Mozambique, the control system for its controllable pitch propeller failed. The ship subsequently made its voyage to Brisbane, Australia, with the propeller’s pitch manually operated from the local control station.

On the afternoon of 29 October 2013, a pilot boarded HC Rubina for its passage in to Brisbane. While the ship was being manoeuvred off its berth, a flexible coupling for the shaft alternator that was providing power to the bow thruster, suddenly failed. The aft end of the engine room rapidly filled with smoke, forcing the engineer controlling the propeller pitch to leave the local station. Consequently, the ship’s propulsion was no longer being controlled and the ship made contact with the wharf, sustaining minor damage.

What the ATSB found

The ATSB found that HC Rubina’s shipboard planned maintenance system provided no guidance for the maintenance of the shaft alternator’s flexible coupling.

The ATSB investigation also identified a number of other safety factors. The ship’s managers did not ensure that the defective propeller pitch control system was reported as required to relevant organisations to allow them to consider the risks arising from the defect. Further, the method used by the ship’s agent, in Brisbane, to collect information for the port’s online booking system did not ensure that such defects were captured.   

The increased risk arising from the ship’s defect and the weather conditions leading up to the incident were factors that should have been considered to determine whether the pre-prepared passage plan remained appropriate.

Although it did not directly contribute to the incident the ATSB investigation did note that at a critical time during the incident, the crew communicated in Russian instead of English, the mandated working language for all ship’s bridges. As a result, the pilot was left out of the communication loop and his ability to make informed decisions was limited.

What’s been done as a result

Maritime Safety Queensland (MSQ), Queensland’s maritime regulator, has updated the training that it provides to the state’s ship agents to raise awareness regarding the gathering of information and reporting of ship defects. Further, MSQ, in conjunction with Brisbane Marine Pilots, has revised the procedure used to exchange information between vessel traffic services (VTS) and the pilot. Specific emphasis was placed on the reporting of defects that could affect the safe navigation of the ship.

HC Rubina’s agent in Brisbane has revised the method used for collecting information, from ship masters, by including a question that specifically asks if the ship has any defects.

Safety message

The incident highlights the importance that needs to be given to the maintenance of critical items of ship equipment and the reporting of their operational condition. Doing so can ensure that pilotage and other high risk operations can be appropriately pre-planned and managed to reduce the likelihood of an incident.

On 29 October 2013, at about 0645 Central Standard Time, the pilot of a Cessna 404 aircraft, registered VH-HAZ, was preparing for a return flight from Darwin to Garden Point and Snake Bay, Northern Territory. The pilot reviewed the applicable Notice to Airmen (NOTAMs) and noted that the runway 11 threshold at Darwin would be displaced due to works in progress. He reported that, on reading the NOTAM, he paid attention to the usable runway length and included the runway distance calculations in his pre-flight planning.

At about 0745, the aircraft departed from the runway 11 ‘Bravo 2’ intersection and the pilot reported that he did not observe any markings indicating the location of the displaced threshold.

On return to Darwin, at about 1000, the pilot received the automatic terminal information service (ATIS), which advised of the displaced threshold. He received a clearance from air traffic control (ATC) to land on runway 11.

While on approach, at about 200 ft above ground level (AGL), the pilot observed orange cones (works limit markers) and red and white cones (unserviceability markers) on the runway. He adjusted the aircraft’s descent profile, aiming to be over the red and white cones at about 50 ft AGL. He then focused his attention on landing. The aircraft touched down near the ‘Bravo 2’ intersection.

The pilot reported that, after completing his flying duties at about 1830, he was notified by his company that ATC had advised that the aircraft had landed before the displaced threshold.

Aviation Short Investigation Bulletin - Issue 25

On 14 October 2013, the crew of a Virgin Australia Airlines Boeing 737 aircraft, registered VH VUC, were preparing for a scheduled passenger service from Darwin, Northern Territory to Melbourne, Victoria.

In preparation for the flight, the first officer (FO) prepared two take-off data cards (TODCs), one for a runway 11 full length departure and another for an intersection departure from taxiway ‘Bravo 2’ (B2). The data for a full length departure was entered into the flight management computer (FMC).

The captain conducted an independent check of the take-off performance data and the data entered into the FMC. The TODCs were then placed on the centre pedestal.

The aircraft was taxied to the B2 intersection holding point where the crew were advised by air traffic control of two inbound aircraft, which would delay a full runway length departure. Consequently, the crew elected to depart from the B2 intersection. The FO re programmed the FMC with the take-off performance data previously transcribed on the TODC for that departure and subsequently cross-checked by the captain.

After take off, the crew noted that the TODC for the full runway length departure was visible on the centre pedestal, on top of the intersection departure TODC. The crew discussed whether the take off from the B2 intersection was conducted based on the take-off performance data for a full runway length departure. While the crew were unable to determine what data was used, in the interests of safety, the event was reported.

The operator conducted an investigation into the incident and identified that the aircraft departed from the runway 11 B2 intersection using the take-off performance data for a full length runway departure.

Errors involving take-off performance data calculations and data entry probably occur frequently, but in most cases, there are sufficient defences in place to detect these errors prior to the aircraft leaving the gate. However, as there is varying take-off performance data calculation methods used by airlines, different aircraft involved, and different aircraft systems used to calculate and enter take-off performance data, there is no single solution to ensure that such errors are always prevented or captured.

Aviation Short Investigations Bulletin - Issue 31

Safety summary

What happened

At about 2000 on 29 October 2013, the general cargo ship Bosphorus grounded at Lytton Rocks Reach in the Brisbane River after the ship’s helmsman unintentionally put the helm the wrong way.

By the time that the Brisbane Marine Pilot on board the ship realised that the helm had gone the wrong way, it was too late to prevent the ship from grounding in the narrow section of the river. There were no reported injuries, damage or pollution as a result of the grounding.

What the ATSB found

The ATSB’s investigation found that the application of incorrect helm was not identified by the ship’s crew and that the ship’s safety management system documentation provided no guidance in relation to the allocation of function based roles and responsibilities to members of the bridge team during pilotage. 

The investigation also found that the navigational watch was handed over at a critical point of the pilotage and the risks associated with this change were not considered. Furthermore, neither the ship’s safety management system nor the Brisbane Marine Pilots’ passage plan detailed any guidance or instructions relating to handing over the watch or helmsman during high risk areas of the pilotage.

What's been done as a result

Brisbane Marine Pilots has amended their safety management system procedures to address all of the contributing factors specific to pilotage issues detailed in this report. Their risk management team has amended the passage plan specifically related to watch hand overs and changing of the helmsman.

Safety message

While functional roles and responsibilities should always be clearly assigned to each bridge team member, the pilot, the master and the officer of the watch should all check the rudder angle indicator before and after each helm order.

On 27 October 2013, the pilot of a Rockwell 114 aircraft, registered VH-AYH, departed Camden Airport, New South Wales in visual meteorological conditions on a flight to the designated training area located near Camden. The pilot was the only person on board.

About 5 minutes after departure the pilot became concerned about the level of smoke from a bush fire in the area effecting visibility. The pilot elected to return to Camden and to conduct circuits.

Due to the reducing visibility from the smoke the pilot conducted low level circuits and continued to monitor the visibility during the circuits. The first touch-and-go was conducted without incident. The pilot configured the aircraft for a second touch-and-go on runway 06. As the aircraft touched down at about 0745 Eastern Summer Time (ESuT) the pilot reported hearing a scraping sound and noticed that the landing gear was not selected down. The aircraft came to rest about a third of the way down the runway. The pilot was not injured.

The pilot indicated he did not remember hearing the aircraft’s landing gear warning horn at any stage during the landing.

This accident highlights the impact distractions can have on aircraft operations and the need to develop systems for managing distractions.

Aviation Short Investigations Bulletin - Issue 30

What happened

At about 1415 Eastern Daylight Time on 25 October 2013, an amateur-built Lancair Legacy aircraft, registered VH-ICZ, with the pilot and one passenger on-board, took off from Shepparton Airport, Victoria, for a flight to Yarrawonga, Victoria. Witnesses reported that the take-off and initial climb appeared normal, however shortly after, the aircraft’s pitch angle increased, after which it entered a descending right turn. The turn and descent continued until the aircraft collided with terrain alongside the airport boundary, fatally injuring the occupants and destroying the aircraft.

What the ATSB found

The ATSB found that shortly after take-off, and for reasons which could not be determined, the aircraft entered a steep climb, likely entered an aerodynamic stall, and began a descending right turn that continued until the aircraft collided with terrain.

The ATSB’s investigation was limited by the degree of damage to the aircraft and the presence of burnt carbon fibre. However, there was no evidence of any pre-existing mechanical fault with the aircraft and engine that could have contributed to the accident. A number of other possible contributing factors were considered and could not be completely discounted; those included sudden pilot incapacitation, aircraft handling, or the aircraft’s weight and balance being outside the design limits.

The aerodynamic characteristics of the aircraft design were such that it could enter a partial or completely stalled condition with little warning. The aircraft was not required to be (and was not) fitted with an angle-of-attack indicator or stall warning device.

The ATSB’s investigation found a number of instances where the regulatory requirements relating to the maintenance and operation of the aircraft had not been appropriately complied with. While the ATSB found no evidence that those non-conformances had brought about, or directly contributed to the accident, they did individually and collectively increase the risks associated with the aircraft’s operation.

Safety messages

Although amateur-built aircraft 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 further defence against the inadvertent approach to, or entry into an aerodynamic stall.

While amateur-built experimental aircraft are not required to comply with the full range of safety regulations that are applicable to commercially-manufactured aircraft, the regulations that do apply are fundamentally important and have been introduced to control and reduce (as much as possible) the risks associated with the operation of this category of aircraft.

The ATSB research report AR-2007-043(2) makes numerous conclusions on the higher accident and fatality rates associated with amateur built aircraft operations. Pilots and passengers need to remain cognisant of the increased risks when flying in this category of aircraft.

On 15 October 2013, the pilot of a Robinson R44 helicopter, registered VH-TZE, was conducting gravity survey work, north of Daly Waters, Northern Territory. On board were the pilot and a geophysical field technician. The survey consisted of landing about every 4 km along a planned grid to collect data. 

At about 1630 Central Standard Time (CST), the pilot conducted a routine landing at a designated grid point. The technician disembarked with his equipment to carry out a reading, about 5 m away from the helicopter. 

A short time later, the pilot saw the technician waving his arms in an attempt to gain his attention. The pilot looked toward the rear of the helicopter and saw a fire underneath, which was spreading into the engine bay. The pilot exited the helicopter and notified the landholders via phone so they could construct fire breaks to contain the ensuing grass fire. The occupants were uninjured; however, the helicopter was destroyed by the fire.                 

The Australian Transport Safety Bureau (ATSB) has been notified of 13 occurrences since 2000 where a helicopter has been destroyed by grass fire, with many reports highlighting the speed with which the grass ignited and the fire spread beyond control.

Robinson R22 and R44 helicopters have exhaust systems that are low to the ground. The Pilot Operating Handbook for both types has a note in Section 10, Safety Tips stating:

‘Do not land in tall dry grass. The exhaust is low to the ground and very hot; a grass fire may be ignited.’

Pre-flight briefings highlighting the dangers of landing on grass, especially in areas of high temperatures and low humidity, can reinforce the importance of carefully choosing a landing site.

Aviation Short Investigations Bulletin - Issue 29

On 20 October 2013, the pilot of a Beech 95 B55 aircraft, registered VH TLP, was conducting a local private flight from St. Helens aerodrome, Tasmania.

The pilot commenced the take-off on runway 26 and, as the aircraft became airborne at about 50-60 ft above ground level (AGL), the pilot reported hearing a bang and the door opened. The pilot continued the climb to 1,000 ft AGL in preparation to return for landing. The pilot could not recall retracting the landing gear after take-off.

When on the downwind leg of the circuit, the pilot attempted to close the door, but was unable to reach it. On turning base, the pilot selected 10 degrees of flap. On final, he selected full flap and reduced the throttle setting to idle for landing.

As the aircraft touched down, the pilot realised that the landing gear was still retracted. The aircraft slid along the runway and came to rest about 600 m from the runway end.

This accident highlights the impact distractions can have on aircraft operations.

Aviation Short Investigation Bulletin - Issue 25

On 22 October 2013, at about 0850 Eastern Daylight-savings Time (EDT), a flight instructor and student pilot of a Schweizer 269C helicopter, registered VH-HYD (HYD), taxied to the southern helipad to conduct circuits at Moorabbin Airport, Victoria. 

Runway 17 Left (17L) was the designated runway in use at the time. The helicopter circuit area was the ‘Eastern Grass’, defined as the area extending from 20 m east of, and parallel to, runway 17L to the perimeter fence.

At about 0914, the pilot of a Piper PA 31 aircraft, registered VH-IBI (IBI), requested a clearance for an IFR flight to Barnbougle Dunes, Tasmania and commenced taxiing for runway 17L. At about 0917, the pilot of an aircraft taxiing for circuits reported ready at the holding point for runway 17L.

To facilitate re-sequencing of the aircraft, the controller opted to change the departure runway for IBI from runway 17L to runway 13L. At this time, the helicopter, HYD, was on the runway 31 Right threshold at the far end of runway 13L, however the controller did not see the helicopter when conducting a scan of the runway prior to clearing IBI for take-off.

At about 0918, the controller cleared IBI for take-off from runway 13L. The pilot of IBI sighted the helicopter ahead, on the runway centreline, when about two-thirds of the way along the runway. As the aircraft had already exceeded the minimum rotate speed, the pilot continued the take-off, increased the aircraft’s angle of climb, and IBI passed about 100-200 ft above HYD.

As a result of this investigation, Airservices Australia has committed to review procedures at Moorabbin Airport.

 Aviation Short Investigation Bulletin - Issue 28