On 5 December 2012, containerised grain train 8448N, travelling from Gilgandra to Walsh Island (Newcastle) was undergoing a roll-by examination at Gulgong, NSW, when inspectors noted a significant structural failure within the number-20 wagon of the consist. The wagon (SQDY 00060-G) had fractured transversely through the central box section main longitudinal member.

The NSW Office of Transport Safety Investigations (OTSI) was responsible for investigating this occurrence. To facilitate the examination of the technical and metallurgical aspects of the failure, OTSI requested assistance from specialist staff at the Australian Transport Safety Bureau (ATSB). To facilitate that assistance and afford the necessary protections to any sensitive information obtained during the course of the work, the ATSB initiated an External Investigation under the provisions of the Transport Safety Investigation Act 2003.

On 16 January 2013, an ATSB specialist examined the failed wagon (and a second wagon that had presented cracking) alongside representatives from OTSI, the NSW Rail Safety Regulator and the wagon maintenance provider. Subsequently and throughout the investigation, the ATSB provided advice and commentary; including a review of the draft investigation reports and a failure investigation report commissioned by the operator.

The NSW Office of Transport Safety Investigations is responsible for releasing a final investigation report into this occurrence – all inquiries regarding the investigation or the report release should be forwarded to the OTSI.

• NSW Office of Transport Safety Investigations website

What happened

At about 1440 Eastern Daylight-saving Time on 22 January 2013, the pilot of a Cessna U206F amphibious aircraft, registered VH-UBI, was conducting a seaplane joy flight from Corio Bay, Victoria with two passengers on board. During the flight the pilot refuelled the aircraft at Barwon Heads Airport, necessitating the use of the landing wheels. On the return trip the pilot detoured for local sightseeing before heading back to Corio Bay for a water landing. On touchdown, the aircraft pitched over and came to rest inverted. The pilot assisted the two passengers to evacuate the aircraft before rescue vessels arrived. All three occupants sustained minor injuries. The aircraft was substantially damaged.

What the ATSB found

The ATSB found that the pilot was distracted during the departure from Barwon Heads and as a result did not retract the landing wheels during the after-take-off checks. The investigation also determined that on returning to Corio Bay, the pilot shortened the approach due to perceived time pressure and did not complete the normal downwind and short final checks. In not completing those checks, the pilot reduced the likelihood of identifying that the landing wheels were still extended. Such events where individuals forget to carry out an action due to distractions are not uncommon and are described as skill-based lapses.

Safety message

This accident is a reminder for pilots and operators that human error can occur at any time, and highlights the importance of managing operational pressures and avoiding distractions. The need to follow procedures and complete checklists diligently is also reinforced. Effective application of threat and error, and distraction management principles can reduce risk.

The operator’s requirement for passengers to wear life jackets throughout the flight enhanced the survivability of the passengers.

Safety summary

What happened

At about 0940 on 31 January 2013, a Queensland Rail passenger train failed to stop at the Cleveland station platform and collided with the end-of-line buffer stop, the platform and the station building at a speed of about 31 km/h. There were 19 people on board the train (including the driver and a guard); three people were on the platform and five were in the station building. A number of people were treated for minor injuries and transported to hospital for further examination.

At the request of the Queensland Government, the ATSB initiated an investigation into the accident.

What the ATSB found

The information contained in this preliminary report is derived from the initial investigation. The object of an ATSB safety investigation is the early identification of safety issues so that action can be taken to reduce any safety-related risk. Since the investigation is on-going, readers are cautioned that new evidence may become available that alters the circumstances depicted in this report.

Based on evidence available to date, the ATSB has found that local environmental conditions resulted in the formation of a contaminant substance on the rail running surface. This caused poor adhesion at the contact point between the train’s wheels and the rail head. The braking effectiveness of T842 was reduced as a result of reduced adhesion and the train was unable to stop before hitting the end-of-line buffer stop.

The ATSB has concluded that Queensland Rail’s risk management procedures did not sufficiently mitigate risk to the safe operation of trains when local environmental conditions result in contaminated rail running surfaces and reduced wheel/rail adhesion.

What's been done as a result

The ATSB has recommended that Queensland Rail take action to address the safety risk associated with contaminated rail running surfaces which lead to reduced wheel/rail adhesion.

Queensland Rail have proposed and initiated a precautionary risk mitigation strategy in response to the collision of train T842 at Cleveland station on 31 January 2013. The strategy includes the formation of a Wheel Rail Interface Working Group tasked to specifically identify and assess any potential wheel/rail interface risks, particularly for Queensland Rail’s fleet of 160/260 class trains being operated under certain conditions.

Queensland rail have also implemented precautionary risk controls including identifying and treating rail-head contaminants at any localised black spot locations, a review of train speed limits around the network and by providing drivers with enhanced train handling advice. 

Safety message

Rail operators should recognise that train braking performance may be significantly impaired when local environmental conditions result in contaminated rail running surfaces and reduced wheel/rail adhesion. Rail operators should put appropriate measures in place to assess and mitigate the risk to the safe operation of trains under these conditions.

History

The Australian Transport Safety Bureau (ATSB), at the request of the Queensland Government, has commenced an investigation into the passenger train accident at Cleveland Station in Brisbane on 31 January 2013.

The accident occurred when a QR passenger train over-ran the Cleveland station platform colliding with the end-of-line buffer-stop, the platform and the station building. There were 15 people on board the train (including the driver and a guard) while four people were on the platform and in the station building. A number of people were treated for minor injuries and transported to hospital for further examination.

Update 1 March 2013

The ATSB’s Cleveland investigation team continues to work hard gathering and analysing a very large amount of information associated with the accident.

A preliminary factual report on this accident will be released within ten days.

Update 14 February 2013

As part of its on-going investigation, the ATSB conducted a series of tests last night on a Queensland Rail passenger train similar to the train involved in the Cleveland station accident.

The ATSB investigation team included the Investigator in Charge and recorded data specialists.

The testing focused on the train braking system and its performance under a range of track conditions. The raw data obtained from the testing is currently being analysed by the investigation team. If any safety issues are identified from that analysis, the ATSB will immediately bring it to the attention of QR.

A preliminary factual report on this accident will be available within two weeks.

Update 12 February 2013

The ATSB investigation team, comprising six senior investigators, have interviewed a range of critical witnesses including the train driver, guard, passengers and other QR train drivers as relevant. They have completed the download of the train’s data loggers and are in the process of analysing this information. Inspections on the train are continuing with a focus on the braking system and a braking test on a similar train will be conducted in the coming days. The rail line leading into Cleveland Station has been inspected and scanned using laser equipment. The team continues to liaise with the Department of Transport and Main Roads and Queensland Rail to gather all relevant evidence.

The ATSB expects to release a preliminary factual report within a month of the accident.

More information will be made available as it comes to hand.

Update 5 February 2013

The ATSB investigation team, comprising five senior investigators, have interviewed the train driver and guard. They will complete the download of the train’s data loggers and commence the inspection and testing of the train’s brake system in a test facility today. The team will continue to liaise with the Department of Transport and Main Roads and Queensland Rail to gather all relevant evidence and is also making contact with other witnesses to arrange interviews before the end of the week.  

The ATSB expects to release a preliminary factual report within a month.

More information will be made available as it comes to hand.

On the evening of 28 January 2013, VH‑YFF was being prepared for a scheduled passenger service from Canberra, Australian Capital Territory to the Gold Coast, Queensland. The crew were aware of adverse weather conditions being experienced at the time in south-east Queensland and had been monitoring the weather at the Gold Coast throughout the day.

During the approach, the crew reported that they were in cloud and experiencing rain and a strong right crosswind of about 40-50 kt. The Tower controller advised the crew that the crosswind on the ground was 21 kt. The captain reported that he was mindful of the wind conditions and was prepared to initiate a go-around.

At about 1,000 ft above mean sea level (AMSL), the crew became visual with the runway.

At about 100 ft, the captain noted that the airspeed trend vector was indicating a 20 kt decrease, likely the result of undershoot windshear. The captain momentarily increased engine thrust.

At about 2229, the aircraft touched down about 200 m further along the runway than intended. The first officer (FO) recalled the aircraft touched down on, or slightly right of the runway centreline. At that time, they were experiencing light rain.

After touchdown, the captain perceived that the aircraft was close to the left side of the runway, due to the proximity of the runway edge lights. The captain immediately applied right rudder, however, he inadvertently overcorrected, resulting in the aircraft veering to the right side of the runway. The captain applied left rudder, and the runway centreline was regained. The aircraft was slowed to taxi speed and taxied to the terminal.

Due to the weather conditions and high workload at the time, the captain was not certain if the aircraft was pointing towards the runway edge before touchdown or if the aircraft aquaplaned after touchdown. The FO reported that it felt like the aircraft aquaplaned and drifted to the left.  However, after reviewing the flight data, the captain believed that the aircraft flared on centreline and drifted left before touchdown.

Through its SafetyWatch initiative, the ATSB is highlighting an increasing trend in problems with aircraft handling and flight profile when unexpected events arise during the approach to land. When compared to other phases of flight, the approach and landing has a substantially increased workload. Further details are available at www.atsb.gov.au/safetywatch/handling-approach-to-land.aspx

Aviation Short Investigation Bulletin  - Issue 23

Safety summary

What happened

On 30 January 2013, Pacific National freight train 9837, travelling from Nowra to Orange, passed signals SM109G and SM115G at stop on the Down Goods line between Dulwich Hill and Hurlstone Park in Sydney. Just prior to this incident a work crew had been working on the track under the protection of Absolute Signal Blocking (ASB). There were no injuries or damage.

What the ATSB found

The ATSB’s investigation found that the train crew did not take action in response to the indications of three consecutive signals, resulting in the passing of two of those signals at stop without authority (also called a SPAD). It was found that the more senior co-driver had inadvertently fallen asleep on the approach to these signals. The trainee driver, in a reduced state of alertness, missed the first signal at caution, and the next signal at stop. He applied the brakes once the train passed the final signal at stop after realising this signal applied to his train.

Two persons from a litter pickup work crew were on the track just before the train passed through their worksite. Once alerted to the train’s approach they moved off the tracks and to a safe place behind the platform at Hurlstone Park station.

A number of Pacific National’s policies and procedures were examined to determine if any area of the management or training of the train crew contributed to the incident. Fatigue management, and in particular over- reliance on the use of bio-mathematical model scores used to roster train crew, was one area where improvement was needed. The ATSB also found that there was an absence of adequate procedures and training for drivers who were performing co-driving duties while coaching trainee drivers.

What's been done as a result

As a result of the incident Pacific National has undertaken a range of actions to improve its approach to fatigue management and the implementation of fatigue training. They have also commenced a review of SPAD risk management processes and training requirements for coach/tutor drivers. A trial has commenced of improved data loggers for the Bulk Rail fleet.

Safety message

In order to minimise fatigue-related errors, rail operators should ensure that fatigue management systems incorporate integrated and multi-layered risk control mechanisms. Rail operators should also recognise that the training of drivers by advanced drivers during operations increases exposure to workload and other risks that need to be managed. In addition, SPAD strategies devised by rail operators should have regard to broad systemic issues rather than focus simply on individual train crew actions.

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 29 November 2012, the ATSB commenced an investigation into a loss of separation involving two Qantas Airways Airbus A330s, registered VH-EBM (flying as QFA485) and VH-QPC (flying as QFA762). The loss of separation took place approximately 148 km east of Narrogin, Western Australia, on 28 November 2012 with the aircraft on crossing tracks.

VH-EBM was inbound to Perth maintaining flight level (FL) 380[1] and VH-QPC was outbound from Perth on climb to FL 410. A short-term conflict alert was received by the controller as VH-QPC climbed through FL 370, approximately 15 NM (about 28 km) before the aircraft passed.

In response, the controller initiated compromised separation recovery actions. During this recovery action, separation between the two aircraft reduced to 2.84 NM (5.26 km) laterally and 900 ft vertically. There were no traffic collision avoidance system[2] alerts.

In reviewing the information gathered during its investigation, the ATSB determined that there were no associated safety issues or elements of the occurrence that have not already been covered in detail in other recent air traffic-related investigations (see AO-2011-090, AO-2012-012 and AR‑2012‑034).[3] The controller in question had completed compromised separation recovery training and had 8 months consolidation on this sector following their initial rating and en route endorsement. There were no identified training, rostering, fatigue or staffing issues and sector handover/takeover was not a factor. While the controller involved had been under moderate to high workload earlier in the shift, the workload was low at the time of the occurrence and there was no evidence that distraction was a factor.

The controller was responsible for two airspace sectors at the time of the occurrence. Airservices Australia has since undertaken significant work in re-structuring the sectors in the airspace over Western Australia. Although the ATSB determined that required voice coordination between sectors was not completed by the controller in this occurrence, this did not affect the controller’s awareness of the traffic as he was already interacting with the aircraft that were involved in the occurrence.

The ATSB did not find any organisational or systemic issues that contributed to the occurrence or that might adversely affect the future safety of aviation operations. On that basis, the ATSB has decided to discontinue its investigation.

Background information

Derailment location

The derailment occurred at the 2446.100 km point of the Tarcoola to Darwin railway line at Katherine, Northern Territory on the No. 219 points that provides access from the crossing loop to the north end of the goods loop.

Track

The railway line between Alice Springs and Darwin, Northern Territory was owned, operated and maintained by Genesee & Wyoming Australia Pty Ltd (GWA).

The rail yard at Katherine consisted of a bi-directional main line, crossing loop and goods loop (west side of the crossing loop). There was a small siding off the crossing loop at the southern end of the yard.

No. 219 points is a right hand turnout, hand operated and comprised of 47 kg/m rail fastened to steel sleepers using resilient clips and a ballast bed with a minimum depth of 150 mm.

Train information

The Ghan passenger train was operated by Great Southern Rail Limited (GSR) between Darwin and Adelaide, South Australia twice a week. GSR contracted the responsibility for train operations to Pacific National (PN), who provided locomotives and drivers under a ‘hook and pull’ agreement. At the time of the derailment, The Ghan consisted of two locomotives (NR 106 leading and NR109 dead attached), 29 coaches (including power vans) and one motorail wagon. There were 194 passengers, 31 hospitality staff and four train drivers on board. The train was 758 m long (including locomotives) and weighed 1585 tonnes.

What happened

On Wednesday 30 January 2013 at 1014 Central Standard Time, The Ghan, train 4DA8 departed Berrimah Passenger Terminal in Darwin.

At 1217, 4DA8 was issued a train authority to proceed to Katherine and take the crossing loop to cross train 2AD1. At 1415, 4DA8 entered the Katherine crossing loop at 29 km/h6 with 2AD1 standing on the mainline. The crew sighted and cross-called the point indicator for No. 219 points, which was correctly set (yellow circle) for 4DA8 to continue heading south on the crossing loop.

Approximately 50 m from No. 219 points, the co-driver noticed that the right hand point blade did not look quite right and alerted the driver. About 20 m from the points, the driver applied the brake to slow the train in response to the co-driver’s concern. When the co-driver confirmed that the two locomotives and first coach had traversed No. 219 points without incident, the driver released the brake. The co-driver continued to monitor the progress of the train over No. 219 points via the side, rear-view mirror and advised the driver that a passenger coach had derailed. The driver immediately reapplied the brake and 4DA8 stopped about 15 seconds later.

When 4DA8 stopped, the front portion of the train was standing on the crossing loop while the rear portion was standing on the mainline. There were no reported injuries to passengers or train crew.

The two locomotives, the first coach and the leading bogie of the second coach had passed through the points correctly following along the crossing loop. The trailing bogie of the second coach and the leading bogie of the third coach derailed into the goods loop. The trailing bogie of the third coach, the fourth and fifth coaches took the crossing loop and remained on track. The leading wheelset of the sixth coach had also commenced to track incorrectly towards the goods loop. All vehicles remained upright and coupled.

What happened

On 10 January 2013, the crew of an Embraer Regional Jet 170 (E170), registered VH-ANO and operated by Airnorth, were flying from Darwin to McArthur River Mine, Northern Territory. Shortly after passing navigational waypoint SNOOD, 125 NM (232 km) north-west of McArthur River Mine, the aircraft’s flight path started diverging from its planned track. The problem was identified by air traffic control and the crew were advised. The aircraft was re-cleared direct to the initial approach fix and continued to McArthur River Mine.

What the ATSB found

The ATSB found that, while updating the aircraft’s flight management system for the descent into McArthur River Mine, the crew unintentionally omitted entering an intended navigational waypoint that was located 25 NM (46 km) north-west of McArthur River Mine. This omission resulted in the aircraft’s autopilot tracking the aircraft direct to the initial approach fix instead of first tracking to the intended waypoint. The crew’s crosschecking processes were not effective in identifying the data input error.

Although it could not be concluded as contributing to the crew’s errors, the ATSB also found that, due to restricted sleep in the previous 24 hours, the crew were probably experiencing a level of fatigue known to have a demonstrated effect on performance. Although the operator’s rostering practices were consistent with the existing regulatory requirements, it had limited processes in place to proactively manage its flight crew rosters and ensure that fatigue risk due to restricted sleep was effectively minimised.

What's been done as a result

Airnorth advised that since the occurrence, the number of E170 flight crew has been augmented, increasing its rostering flexibility. Furthermore, due to schedule changes, the operator no longer used any roster pattern that resulted in planned rosters with flight crews receiving less than 10 hours time off duty overnight.

Although not in response to this occurrence, the Civil Aviation Safety Authority has released revised fatigue management and flight and duty time requirements in Civil Aviation Order (CAO) 48.1 Instrument 2013. These new requirements either require operators to have a fatigue risk management system, or operate to more restrictive requirements regarding minimum time off duty than those which previously applied.

Safety message

This occurrence reinforces the importance of all pilots and operators conducting systematic and comprehensive checks of all data entered into flight management systems, and the importance of continually monitoring the effects of data input on an aircraft’s flight path.

On 19 January 2013, a Robinson R22 Beta II helicopter departed from a station homestead, located 10 km to the east of Manton Dam, Northern Territory. On board the helicopter were a pilot and a passenger.

On return to the homestead and on approach to land, the pilot reported that he had difficulty maintaining control of the helicopter in the hover and he elected to conduct a go-around. At about 40 ft above ground level, and at an airspeed of between 25 to 30 knots, the helicopter suddenly yawed to the right and completed 3 to 4 revolutions before impacting trees. The helicopter came to rest inverted and was seriously damaged. The pilot was able to exit with minor injuries and assisted the passenger, who was seriously injured, to exit the helicopter.

Wind will cause anti torque system thrust variations to occur in helicopters. Certain relative wind directions are more likely to cause tail rotor thrust variations than others. Knowing which direction the wind is coming from is critical – especially in light wind conditions. Any manoeuvre, which requires the pilot to operate in a high-power, low-airspeed environment with a left crosswind or tailwind creates an environment where unanticipated right yaw may occur.

Aviation Short Investigation Bulletin - Issue 18

On 19 January 2013, when at the ‘2RN’ VFR approach point, the pilot of a Piper PA-44 aircraft, registered VH-MHZ (MHZ), attempted to broadcast an inbound call to Bankstown Tower, however, the pilot reported that the call was over-transmitted. Shortly after, a second inbound call was broadcast, which the pilot reported was again over-transmitted. The pilot of MHZ determined that communications with Bankstown Tower could not be established due to radio congestion and he elected to maintain his current heading and altitude. The aircraft subsequently entered the Bankstown control zone (CTR) without a clearance.

Soon after, the pilot and passenger of a Hawker G36 aircraft, registered VH-JKL, observed an unidentified aircraft in their 2 o’clock position at about the same altitude. Shortly after, air traffic control advised the pilot of JKL of an unidentified aircraft to the south, about 0.5 NM away. The pilot replied that he would descend and monitor the aircraft. The pilot reported descending 50-100 ft and conducting a slight right turn. As MHZ passed overhead JKL, vertical separation reduced to 200 ft and then increased to 400 ft as JKL descended.

The Civil Aviation Safety Authority visual flight rules guide recommends that pilots should consider initiating radio contact with air traffic control far enough away from the CTR boundary to preclude entering Class D airspace before two-way communications are established. This is particularly important when operating into busy airports such as Bankstown.

Aviation Short Investigation Bulletin - Issue 18