What happened

At 1900 Eastern Daylight-saving Time on 12 January 2012 a Beech Aircraft Corporation 23 (Musketeer) registered VH-DFC (DFC) was on final approach to runway 18 at Mildura aerodrome, Victoria. With one stage of flap selected and passing about 300 ft above ground level (AGL), the pilot responded to a heavy sink rate by applying full throttle.

After climbing slightly, the aircraft then ballooned high. The pilot allowed the aircraft to climb to regain glide path then put the nose down and retarded the throttle to continue the approach. The aircraft then dropped rapidly and impacted runway 18 prior to the intersection with runway 09/27.

The aircraft sustained serious damage when the nose wheel separated from the fuselage. The pilot vacated the aircraft uninjured, while the sole passenger sustained minor injuries.

This accident demonstrates the importance of pre-flight planning for landing variables, such as wind. It also highlights that should an approach become unstable, conducting a go-around may be the safest course of action.

What happened

On 8 January 2012, at about 2141 Eastern Daylight-saving time, a loss of separation assurance occurred between a Boeing Company B737-8FE, registered VH-VUJ (VUJ) and a Boeing Company B737-838, registered VH-VZS (VZS), near Tamworth Airport, New South Wales (NSW).
Both aircraft were conducting scheduled passenger services, under the instrument flight rules, with VUJ operating from Sydney, NSW to Brisbane, Queensland and VZS operating from Brisbane to Sydney. Due to weather diversions, the aircraft were operating on reciprocal tracks at the time of the occurrence.

The air traffic controller assigned VUJ climb to the same level maintained by VZS. On activation of the air traffic control system's Short Term Conflict Alert (STCA), when the aircraft were 17.5 NM (32.4 km) and 2,200 ft apart, the controller issued both flight crews instructions that ensured vertical separation was maintained in excess of the required standard and a breakdown of separation avoided.
The controller later reported feeling mentally fatigued following a shift with high complexity and workload. They had not identified the confliction before the STCA, but once aware, the controller's knowledge and application of effective compromised separation recovery techniques was integral in managing the situation.

Following the occurrence, Airservices Australia advised that compromised separation recovery refresher training would be provided to controllers again, in addition to sessions on separation assurance techniques, and that they were implementing a renovated Fatigue Risk Management System and a Normal Operations Safety Survey program.

This incident highlights the need for awareness of the effects of high workload and sustained task complexity on performance, the importance of regular breaks and implementation of strategies, such as the use of conforming levels, when able. In addition, the knowledge and application of effective compromised separation recovery techniques by air traffic controllers is integral in the management of compromised separation situations.

What happened

During the morning of 3 January 2012, the pilot of a Robinson Helicopter Company R22 helicopter, registered VH-FHR, was conducting low-level aerial work along the Dutton River, 45 km east-north-east of Richmond Aerodrome, Queensland. The pilot was the sole occupant. At about 1130 Eastern Standard Time, when at about 20 to 30 KIAS and 250 ft above ground level, the pilot felt a 'kick' to the helicopter and the machine suddenly yawed to the left. Shortly after, a second 'kick' and yaw occurred, followed by the sounding of the low rotor RPM warning horn. The pilot entered autorotation and attempted to recover forward airspeed with the little height he had at the time.

The pilot was unable to arrest the helicopter's rate of descent before the machine impacted the sandy riverbed heavily and rolled onto its right side. A post-impact fire commenced immediately, but the pilot was able to egress with minor burns. The helicopter was seriously damaged on impact and subsequently destroyed by the post-impact fire.

The 'kicks' and yaw experienced may have been due to environmental effects such as the effect of the gusting and swirling winds and mechanical turbulence.

This accident highlights the need for helicopter pilots to be mindful of conducting operations with a combination of forward airspeed and altitude which may place the machine in the 'avoid' area of the respective height velocity diagram.

Helicopter pilots who regularly fly at low altitude may consider the benefits afforded by the wearing of helmets and additional personal protective clothing and equipment.

Safety summary

What happened

On the morning of 8 January 2012, one of the permanent mooring lines holding the general cargo ship Tycoon in position in the inner moorings at Flying Fish Cove, Christmas Island, came free from its anchor. As a result, the ship moved forward and closer to the nearby terminal rock face, eventually making contact with the rock face as the weather and sea conditions deteriorated.

Despite attempts to move it away, Tycoon continued to pound against the rock face. Eventually, the ship’s engine room began to flood through a tear in the hull. Shortly afterwards, the crew safely abandoned the ship.

At about 1100 on 9 January, Tycoon suffered a catastrophic failure of its hull and the contents of the ship’s number two cargo hold, about 260 tonnes of bagged phosphate, were exposed to the sea. The ship continued to be pounded by the sea and swell and, over the following months, it broke up under the action of the waves. On 14 May, salvors were appointed and by 26 July the wreck had been removed from Flying Fish Cove.

What the ATSB found

The ATSB found that the shackle connecting the port’s cantilever mooring line to its anchor chain failed and that Tycoon’s master did not advise shore authorities of his concern regarding the deteriorating conditions or that the cantilever mooring line had come free. He also did not make proper use of the ship’s main engine or mooring lines to attempt to keep the ship in position after the mooring line came free.

In addition, it was found that there had been no risk assessment undertaken by successive port managers with regard to the use of the inner moorings and that there was little guidance provided to the masters of ships intending to moor in Flying Fish Cove. Furthermore, the managers of the port had not implemented an effective inspection and maintenance program and therefore were not aware of the deteriorated condition of the aft mooring line shackle.

What's been done as a result

The port operator has started to fly diving contractors into Christmas Island to complete the annual dive inspection and has commenced replacing and upgrading the mooring equipment. They are also developing a Port Handbook which will be provided to the master of each ship and are facilitating safety training workshops that will be a forum through which the risks posed to the port and its operations can be assessed.

Safety message

Those responsible for the management and operation of a port should consider all the risks associated with the operations carried out within the port. As a result, there should be appropriate procedures and contingency plans in place to deal with foreseeable emergencies and effective maintenance and inspection regimes that ensure the good order of equipment and facilities.

Safety summary

What happened

On 30 December 2011, a Bombardier DHC-8-102 aircraft, registered VH-QQA, was being operated on a scheduled passenger service to Cairns, Queensland. During the landing, the crew perceived that the aircraft decelerated much quicker than they expected given that reverse thrust and landing gear brakes had not been selected. A subsequent inspection of the aircraft found nothing to explain the perceived problem, and a review of the flight recorder data indicated that there was no abnormal operation of the engines or propellers, and that reverse thrust had not been used.

What the ATSB found

Although unrelated to the reported occurrence, subsequent inspection of the aircraft identified a design problem within the aircraft’s power lever control quadrant. The problem related to the friction device within the power levers and its interaction with the flight idle gate, which was designed to prevent the power levers from going into the ground range in flight. When the friction knob was wound to the full out (friction off) position, the flight idle gate was lifted by contact between the friction device and the flight idle gate. That action rendered the flight idle gate inoperative.

The design problem only applied to the first 39 DHC-8-100 aircraft that were manufactured; subsequent aircraft were manufactured with a modified design. The aircraft manufacturer introduced a service bulletin requirement in 1986 to retrospectively modify these 39 aircraft, but the service bulletin omitted a requirement to modify or replace a specific part, which resulted in the bulletin being ineffective.

What has been done to fix it

Once informed of the design problem, the aircraft manufacturer took prompt action to address the issue. It issued a service bulletin to modify the relevant part, and this action was subsequently mandated by Transport Canada and the Civil Aviation Safety Authority of Australia.

Safety message

This investigation highlights the importance of crews reporting occurrences and other perceived problems. Although in this case the actual event reported by the crew was not serious, and no problems relating to the aircraft or crew performance leading to the perceived event were identified, the subsequent investigation did identify a safety issue in the design of the aircraft.

What happened

At about 1000 Eastern Standard Time on 4 January 2012, a Cessna 172 N aircraft, registered VH-ZWR, operating under the Visual Flight Rules in G Airspace, was taking off to conduct a charter flight with the pilot and three passengers on board.

When the aircraft had reached about 25 to 30 ft above ground level, after take-off from The Oaks beach at Fraser Island, Queensland, the aircraft descended. The right wingtip struck the beach near the water line and the aircraft came to rest on the left wingtip and nose. The occupants exited the aircraft with minor injuries before the aircraft was turned on its back several minutes later by wave action.

The circumstances of the accident were consistent with an aircraft stalling as it climbed out of ground effect while flying at an airspeed and configuration where the airspeed was unstable.

As a result of this accident the operator has reviewed their soft field take-off procedures.

This accident highlights that pilots should be aware of the effect that flap extension has on the stall attitude of their aircraft, and the need for pilots to be aware of performance variations when conducting a soft field take-off.

What happened

On 23 December 2011, a Robinson Helicopter Company R22 Beta, registered VH-LNC departed Caloundra aerodrome on a Trial Instructional Flight (TIF).  On board the helicopter were an instructor and student.

Whilst attempting to hover the helicopter the student made a significant and unexpected control input.  Before the instructor could take control, the left skid contacted the ground, and the helicopter rolled over and sustained serious damage.  The instructor and student were uninjured.

Robinson Helicopter Company has identified inexperienced individuals manipulating the controls and dynamic rollover as a significant factor in helicopter accidents.  In response to this accident the helicopter operator has introduced a new policy in regard to TIFs and students manipulating the flight controls below 500 ft above ground level.

What happened

On 1 January 2012, at about 0900 Eastern Daylight- savings Time, a Cessna Aircraft Company A188B/A1 aircraft registered VH-ZAP (ZAP) was conducting aerial work about 40 km south of Forbes, New South Wales. During the application of chemicals, the aircraft developed a high sink rate as a result of a downdraught and the left wing impacted trees. The subsequent post-impact fire seriously damaged the aircraft, and the pilot received minor injuries. The pilot reported that he had difficulties activating the emergency dump control system to lighten the aircraft.

This accident highlights the risks associated with executing a turn when in close proximity to the ground. Such manoeuvres require heightened pilot vigilance regarding controlling the aircraft. In addition, pilots must be prepared to immediately identify the situation and act to control the aircraft, in order to compensate for a change in wind direction or downdraughts.

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

On 3 January 2012, the ATSB commenced an investigation into a loading issue involving a Boeing Company 747-438 aircraft registered VH-OJM, at Melbourne Airport, Vic, on 22 December 2011. Examination of the information collected during the investigation identified that the circumstances of the occurrence were limited to incorrect load data being entered onto the provisional loadsheet. The discrepancy was identified by the flight crew and amended prior to the final loadsheet being produced.
 
The operator advised the ATSB that they had identified the nature of the error and had put in place measures to prevent its reoccurrence.
 
Accordingly, the ATSB decided that there was limited potential to enhance transport safety by continuing this investigation and has elected to discontinue it. However, the data already collected may be used by the ATSB for future statistical analysis and safety research purposes.

Safety summary

What happened

At approximately 0542 (CST) on 27 December 2011, freight train 7AD1, owned and operated by Genesee & Wyoming Australia Pty Ltd (GWA), derailed at the Edith River rail bridge near Katherine in the Northern Territory. GWA was also the owner and operator of the rail track.

The train driver was unhurt as a result of the derailment, but the co-driver suffered back injuries and there was significant damage to the bridge and rolling stock. A number of wagons including the crew van, which was unoccupied at the time, derailed into the Edith River.

What the ATSB found

The ATSB determined that the derailment of train 7AD1 was caused by the wash-away of the south-eastern embankment, associated sub-grade and ballast on the approach side of the Edith River rail bridge. The magnitude of the wash-away meant that the track could not support the weight of train 7AD1 as it passed over the affected track. The track collapsed under the train, initiating the derailment.

The wash-away was the result of a severe flood event caused by torrential rains that fell within the Edith River catchment area in the aftermath of cyclone 'Grant'.

What has been done as a result

As a result of the derailment at the Edith River rail bridge, on 27 December 2011, GWA has undertaken a range of actions to enhance its policies, procedures and employee training with respect to managing the risks associated with severe weather events. GWA will also enhance its systems for alerting staff to severe weather events, including flood risks.

Safety message

It is essential that rail network operators have robust systems in place to monitor and mitigate the risks of severe weather events to ensure that the safety of railway operations is not compromised.