At 1314:47 hours the pilot reported that he was ready to descend and was cleared by Cairns ATC to "descend to 4000 feet, not below DME steps". He was requested to report approaching 4000 feet on descent and to advise his in-flight conditions at that time. The pilot read back "four thousand, not below DME steps" and ATC requested him to confirm that the aircraft's DME had "locked on" again. The pilot replied "affirmative and indicating four niner DME".

At 1326:21 hours Cairns ATC requested the pilot to report DME distance, but there was no reply. Further attempts to establish radio contact with the aircraft were unsuccessful. Search and Rescue action was initiated and at 1625 hours a ground party reported finding the wreckage of the aircraft on the southeastern side of Mt. Bellenden Ker.

Examination of the wreckage did not reveal any evidence of unserviceability or malfunction of the aircraft which might have contributed to the accident.

What happened

On 22 May 2012 at 1608 Eastern Standard Time, a Piper PA-34-220T, registered VH-PWQ (PWQ), conducting training under Instrument Flight Rules (IFR) and a Cessna R182, registered VH-JYG (JYG), on a pipeline survey under Visual Flight Rules (VFR) passed within 0.1 NM and 100 ft of each other in Class D airspace at Avalon aerodrome, Victoria.

The air traffic controller had provided traffic information to both aircraft, but the pilot of PWQ stated that the information was not sufficient for him to understand the intended track of JYG.

Traffic information provided by air traffic controllers must be concise, however it needs to include enough relevant reference information to enable the pilot to determine if any avoidance action is required. A recent amendment to documents used by air traffic controllers provided more detail on the provision of safety alerts in all classes of airspace and on when to issue avoiding action within surveillance coverage.

In Class D, where separation is not provided between IFR and VFR aircraft, pilots need to be aware of the limitations of the see-and-avoid principle. Pilots should also be aware of their responsibilities in Class D and conscious of the dangers of expectation.

Aviation Short Investigation Bulletin - Issue 13

Safety summary

What happened

On 25 May 2012, freight train 3PW4 collided with a motor vehicle (Toyota Corolla) that was fouling the railway track at the Cherry Street level crossing in Werribee, Victoria. The passenger in the Corolla died as a result of the collision and the driver was injured and required treatment in hospital.

What the ATSB found

The ATSB found that the driver of the Corolla had entered the level crossing when traffic was flowing relatively freely. Shortly after the Corolla entered the crossing, the lights, bells and boom barriers protecting the crossing began to operate for the approach of train 3PW4. Unbeknown to the Corolla driver, another vehicle had broken down just beyond the crossing. This led to her having to stop the Corolla in a position which was foul of the railway track.

When the crew of train 3PW4 saw the Corolla fouling the track, they made an emergency brake application. However, the train could not be stopped in time to prevent the collision.

The ATSB’s investigation found that the level crossing signage and road markings were generally in accordance with the applicable Australian Standards and that the crossing warning lights, bells and boom barriers had operated correctly.

The ATSB also found that while the collision was a direct result of the Corolla being in a position foul of the approaching train, the safety issues involved were more complex and extensive. The investigation identified several opportunities to enhance the safety of the existing grade crossing including changes to the road design, the provision of short-range warning lights, improving the coordination of the crossing protection system with the nearby pedestrian traffic lights, reducing the length of the crossing and the provision of suitable refuge/escape area(s).

What's been done as a result

Metro Trains Melbourne has advised that they will investigate the potential benefits gained from fitting short range lights at this and other similar level crossings. They have also advised that the options available for shortening the level crossing length will be explored in consultation with the Wyndham City Council.

The Wyndham City Council has advised that actions have been taken to improve the coordination of the nearby pedestrian crossing lights and that further coordination improvements are being considered. Council officers are also investigating ways to provide escape/refuge areas.

Safety message

Although the road rules (Victorian Road Safety Act 2009) make motorists primarily responsible for avoiding a collision with a train when negotiating a level crossing, prudent road and level crossing design is essential in helping to mitigate the risk of road and rail vehicles colliding.

Where it is feasible, road and rail authorities should consider additional measures to enhance the situational awareness of motorists negotiating level crossings and to address the risks associated with traffic queuing.

It is also imperative that motorists approaching level crossings are extremely vigilant.

Safety summary

What happened

On 17 May 2012, the flight crew of a de Havilland Canada Dash 8 aircraft, registered VH-XFZ and operated by Skippers Aviation Pty Ltd, was conducting a circling approach to runway 07 at Laverton Aerodrome, Western Australia. In conditions of low cloud, the crew positioned the aircraft on a close base leg to maintain visual reference with the runway threshold. This led to a steep final approach and a high rate of descent that triggered alerts from the aircraft’s Enhanced Ground Proximity Warning System (EGPWS) and exceeded the operator’s stable approach criteria. The crew heard some alerts from the EGPWS and knew they had a high rate of descent but at the time did not identify an unstable approach. The crew continued the approach and landed.

What the ATSB found

The ATSB found that at the time of the occurrence the flight crew did not have an adequate understanding of operational aspects of the aircraft’s EGPWS and the operator’s standard operating procedures in regard to mandatory go-arounds. Crew fixation on the runway environment at a time of higher than normal cognitive workload and an inadequate monitoring of the aircraft’s rate of descent resulted in the continuation of an unstable approach, contrary to the operator’s procedures. The ATSB also determined that the operator’s minimum height for achieving the criteria for a stable approach was lower than recommended by the International Civil Aviation Organization.

What has been done as a result

In response to this occurrence, the operator implemented a number of safety actions to refine their stabilised approach criteria and formulate a method of incorporating realistic EGPWS warning events in the Dash 8 simulator training program. The intent was to enhance crews’ ability to recognise and respond correctly and rapidly to EGPWS alerts.

Safety message

The ATSB continues to stress the risks associated with the handling of an approach to land. The Flight Safety Foundation cites a lack of go-arounds from unstable approaches as the number one risk factor in approach and landing accidents and the primary cause of runway excursions. This occurrence highlights the importance of crews adhering to standard operating procedures and correctly responding to cockpit warnings.

Safety summary

What happened

On 24 May 2012, three Transfield Services Australia (Transfield) road-rail vehicles were travelling in convoy in a westerly direction between Forrest and Haig in Western Australia, where they were to be taken off the track.

Shortly before 1700, on arrival at the Haig level crossing, the lead vehicle was off-tracked, but a problem with the second vehicle prevented its removal from the track. At about 1711, while work was continuing to remove the second vehicle from the track, the third vehicle in the convoy, a flatbed truck, collided with the rear of the second vehicle. The force of the impact shunted the stationary vehicle forwards with both vehicles running over one worker, fatally injuring him, while the other jumped clear. The driver of flatbed truck was not injured.

What the ATSB found

The ATSB determined that the flatbed truck could not be stopped in time to avoid the collision because the brakes that were originally fitted to its front rail guidance equipment had been removed, and the vehicle’s rear wheel brakes were in a poor state of repair. The investigation also identified that the rail workers had developed localised practices that were not compliant with Transfield’s operational procedures.

A sample of the deceased worker’s blood tested positive to both the active and inactive metabolite of cannabis. The other workers were not tested for the presence of drugs and alcohol following the accident.

The ATSB identified a number of systemic issues associated with Transfield’s road-rail vehicle maintenance regime, rail safety worker training, management oversight and drug and alcohol policy and procedures.

In addition, the ATSB highlighted the absence of a national standard for road-rail vehicles which addresses the fitment, modification and maintenance of road-rail equipment and the consequent risk that unsuitable modifications may adversely affect the safe operation of a road-rail vehicle.

What's been done as a result

Transfield Services Australia has reviewed and updated its road-rail vehicle maintenance regime. The company has also taken action to improve its management oversight of rail safety workers, its training processes for maintenance and operational staff and its drug and alcohol policies and procedures.

The Rail Industry Safety Standards Board (RISSB) is facilitating the development of Australian Standard, AS 7502, Road Rail Vehicles. The standard will cover the basic requirements for road-rail vehicles across their life cycle, including design, construction, testing and certification, operation, maintenance, modification and disposal.

Safety message

Rail operators should ensure that safety critical road-rail vehicle equipment is appropriately maintained. Maintenance regimes and activities should consider the increased loading and wear and tear on the vehicle and its various components as a result of fitting of rail guidance equipment and of the operation of the vehicle on rail.

Rail Operators should also conduct regular reviews of staff members’ and contractors’ ability and competency to ensure they are consistently performing their duties in accordance with the most up to date and endorsed working instructions.

Safety summary

What happened

In the early hours of 18 May 2012, while transiting the Coral Sea, ID Integrity’s main engine shut down when its fuel pump reversing mechanism came free and jammed. This caused the camshaft to bend and slip in a drive coupling which resulted in the camshaft being out of timing and therefore the engine could not be restarted.

The ship drifted in a westerly direction towards the Australian coast and the Great Barrier Reef. During the afternoon of 19 May, the ship passed over Shark Reef, located about 60 miles east of the Great Barrier Reef Marine Park, without incident. The following day, the ship was taken in tow when it was about 35 miles to the east of the marine park and towed to Cairns for repairs.

What the ATSB found

The ATSB found that the engine manufacturer had identified the need for owners and operators to check the fuel pump reversing mechanism for cracks and secureness and provided this advice in service letters. However, on board ID Integrity, this advice had not been included in the engine manuals or planned maintenance system. As a result, over time and despite regular inspections, the system deteriorated and cracks developed in the mechanism undetected. This led to the failure of a fuel pump reversing link on 18 May.

The investigation also found that, once notified, the actions of the various stakeholders were appropriate and the response arrangements were effective.

What's been done as a result

ID Integrity’s managers have implemented a schedule to inspect all main engines in their fleet and undertake repairs as necessary. Staff from all company ships have been made aware of this incident and it has been included in crew training centre courses.

MAN B&W, the main engine designer, reiterated the need to include all service letter advice in manuals and maintenance systems. They also advised that service letters and updated manuals are always available on request through the website www.mandieselturbo.com via the Nexus (Customer extranet) link.

The ship’s classification society, ClassNK, initiated discussions with MAN B&W to enhance its knowledge of engine design and operation changes. ClassNK also improved the content and extent of information provided to its surveyors.

Safety message

Service advice from machinery manufacturers needs to be carefully assessed and implemented as necessary as part of a ship’s planned maintenance system. Furthermore, all associated documentation should be updated and regularly checked to ensure it remains relevant and reflects the latest available information.

What happened

On 16 and 17 May 2012, three aircraft were operated on scheduled passenger flights from Gladstone to Brisbane, Queensland without the runway lights being activated for departure.   

The runway lighting was controlled by a pilot activated lighting (PAL) system that was combined with an aerodrome frequency response unit (AFRU).  To activate the runway lights, pilots were required to make a sequence of three transmissions on the common traffic advisory frequency (CTAF).  A number of situational factors were associated with the crew not activating the runway lights prior to departure.   

Defining a specific place for PAL tasks in the crew’s sequence of procedures, and incorporating this into a pre-taxi checklist, could potentially ensure more reliability in performing these tasks.

Aviation Short Investigation Bulletin - Issue 12

What happened

On 13 May 2012, a Cessna Aircraft Company 208, registered VH-DZQ (DZQ), was conducting parachute operations at Bells Beach near Redcliffe aerodrome, Queensland. At about the same time, an amateur built Van’s RV-8 aircraft, registered VH-YGY (YGY), was on a scenic flight around the Brisbane area.

At about 1229 Eastern Standard Time, DZQ departed Redcliffe aerodrome and at about 1249 dropped nine parachutists from Flight Level (FL) 140 at Bells Beach. The pilot of DZQ made all necessary radio broadcasts prior to and immediately after the parachute drop.

At about 1252, as YGY flew along Bells Beach, the pilot saw four parachutes and made a slight right turn to pass about 150 to 200 ft above and about 50 ft to the right of one parachutist. The location of YGY when the parachute-related broadcasts were made by DZQ meant that the pilot could not have heard the calls.

The incident highlights the importance of accurate information being available to pilots to facilitate an adequate pre-flight brief. The correct placement of parachute symbols on the Brisbane Visual Terminal Chart (VTC) or a NOTAM on current parachute operations would have alerted the pilot of YGY to the potential for parachutists in the Bells Beach area.

The incident also demonstrates the need for pilots to maintain continuous visual scans and not rely solely on radio broadcasts for traffic advice.

Aviation Short Investigation Bulletin - Issue 12

Safety summary

What happened

On 1 May 2012, the pilot of a Piper PA 25-235/A9 (Pawnee) aircraft, registered VH-GWS, was conducting agricultural operations from a local airstrip near Hallston, Victoria. Shortly after take-off, the aircraft collided with terrain near the base of a gully and was destroyed by a post-impact fire. The pilot was fatally injured.

What the ATSB found

The aircraft likely sustained a partial power loss shortly after take-off, resulting in an inability to continue climbing or maintain altitude. Damage sustained during the accident and post-impact fire prevented an identification of the specific reasons for the power loss. The ATSB also found that operation of the aircraft over hilly terrain probably limited the pilot’s emergency landing options and increased the severity of the terrain impact following engine power loss.

What's been done as a result

The investigation did not identify any organisational or systemic issues that might adversely affect the future of aviation safety.

Safety message

Some of the circumstances surrounding this accident are highlighted in the ATSB research report AR-2010-055: Managing partial power loss after take-off in a single-engine aircraft. Pilots and aircraft operators are encouraged to consider the topics covered in that report, which may assist in reducing the risks associated with partial or complete power loss after take-off. In addition, pilots are reminded that the timely dumping of any aircraft payload where possible can assist in improving aircraft performance and may provide additional options for a safe outcome.

What happened

At about 0815 Western Standard Time on 28 April 2012, a Gippsland Aeronautics GA8-TC 320 aircraft, registered VH-WOV, took off from runway 12 at Kununurra airport, Western Australia, for a sightseeing flight over the Bungle Bungle ranges. On board were the pilot and six passengers.

Despite the application of full throttle during the takeoff, the engine manifold pressure was lower than expected. The manifold pressure decreased further soon after the aircraft became airborne, to the point that level flight could not be maintained. The pilot initially prepared for a forced landing, but after finding that sufficient power was available to remain airborne, and assessing the surface of the selected field as unsuitable, the pilot elected to return to the departure airport. The pilot landed on the grass surface of the airport adjacent to the parallel taxiway, with no injuries reported and no damage to the aircraft. The low and decreasing manifold pressure was the result of an engine turbocharger system malfunction.

This incident highlights the importance of understanding the complexities of engine turbocharger systems. A turbocharger system malfunction may result in unpredictable engine power and aircraft performance. Furthermore, a turbocharger system malfunction does not necessarily mean that the engine will behave like a normally aspirated engine. Although this incident was the result of a turbocharger system malfunction, pilots are reminded that abnormal manifold pressure indications may be symptomatic of a serious problem, such as an engine exhaust system leak.

This incident also highlights the importance of pre-flight preparation. Self-briefing may help pilots respond to abnormal takeoff indications more effectively, and help manage the influence of perceived pressure when confronted with a time-critical decision.

Aviation Short Investigation Bulletin - Issue 12