What happened

At about 1450 on 11 October 2011, the third mate on board the Panama registered woodchip carrier Universal Gloria suffered burns to his hands and face when the air compressor he was using to fill an oxygen breathing apparatus (OBA set) cylinder exploded.

The ATSB investigation found that the explosion occurred as a result of a fire that started within the compressor when oil ignited in the hot oxygen-rich environment.

The investigation identified three safety issues. The crew were not appropriately trained or drilled in the operation and maintenance of the ship's OBA sets; the ship's safety management system did not provide the crew with appropriate guidance in relation to the operation and maintenance of the OBA sets; and there were no engineering controls in place to prevent the inadvertent connection of an OBA cylinder to the air compressor.

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 12 October 2011, the ATSB commenced an investigation into the breakdown of separation, between an Airbus Industrie A320 aircraft registered VH-VGR and a Boeing Company 737 aircraft registered VH-VOD near Melbourne Airport, Vic. Examination of the information collected during the investigation identified that the occurrence had significant similarities to aspects of ongoing investigation AO-2010-104, breakdown of separation, between a Boeing Company 767 aircraft registered VH-OGU and a Boeing Company 737 aircraft registered VH-VBH, near Melbourne Airport, Vic on 5 December 2010.

Accordingly, the ATSB decided to examine the 12 October 2011, breakdown of separation event as part of the broader investigation AO-2010-104 and the separate AO-2011-131 investigation was discontinued.

What happened

On 20 September 2011, a Cessna Aircraft 550 Citation II aircraft, registered VH-INT, was involved in a ground towing accident when a Fokker F100 under tow collided with the tail of the parked Citation. The collision resulted in damage to the left elevator, rudder and rudder trim control surfaces that necessitated the Citation undergoing repairs.

On 06 December 2011, while conducting a post-maintenance flight, the crew experienced control problems. The resulting post-flight inspection found several maintenance procedural omissions and rigging inconsistencies.

A review of the maintenance system and processes for return to flight and the acceptance flight versus training flight protocols was conducted respectively by both the maintenance and operator organisations and corrective actions taken.

Safety summary

What happened

At approximately 0105 on 11 October 2011, empty ore train 1901S, operated by Specialised Bulk Rail Pty Ltd, passed signal 13 displaying a stop indication at Dry Creek Junction in South Australia.

Train 1901S subsequently collided with loaded grain train 5132S, operated by Genesee and Wyoming Australia Pty Ltd, that was travelling in the opposite direction and traversing the turnout at Dry Creek Junction to enter the Dry Creek North Yard.

The collision was at low speed and there was no injury to the train crew of either train. There was significant damage to the crew cab of the lead locomotive of train 1901S and to the grain wagons of train 5132S that were struck during the collision.

What the ATSB found

The ATSB determined that the collision between train 1901S and 5132S was a result of train 1901S passing signal 13 at stop (SPAD). The SPAD of signal 13 was a result of the driver-in-training and co-driver (supervising driver) of train 1901S becoming distracted during the approach to the preceding signal, 135, which was displaying a caution aspect indicating that signal 13 ahead was at stop.

The investigation revealed that a combination of individual actions and systemic issues contributed to the collision. The driver’s lack of route knowledge, combined with an expectation of a clear run through the area probably influenced his failure to observe signal 135 at caution. The supervising driver was completing an administrative task that diverted his attention away from the primary task of supervising the actions of the driver-in-training.

The absence of adequate procedures to provide supervising drivers with sufficient direction as to the nature of their supervisory role and to inform of the level of competency attained by a driver-in-training resulted in the breakdown of operational risk controls.

The ATSB investigation explored fatigue impairment as a causal factor related to the SPAD of signal 13. While fatigue impairment was not considered a contributing safety factor in this occurrence, the importance of a rigorous fatigue risk management program subject to continual improvement is highlighted.

What has been done as a result

Following the collision at Dry Creek Junction, Specialised Bulk Rail Pty Ltd amended procedures that clarify the role and responsibilities of a driver supervising a trainee, and introduced arrangements to inform the supervising driver of the trainee’s level of competency.

Safety message

Rail operators must implement robust procedures that systematically manage the supervision, training, and assessment of drivers’ route knowledge to ensure competency and address any risks inherent in the operational task.

What happened

On 8 October 2011, a Cessna Aircraft Company U206F, registered VH-EUW (EUW), was conducting parachute operations at Tooradin aeroplane landing area (ALA), Victoria. At about 1415 Eastern Daylight-saving Time EUW was returning to Tooradin after a parachute flight that was rejected due extensive cloud cover.

When on final for runway 22 at Tooradin the aircraft lost power and collided with terrain approximately 0.75 nm northeast of the threshold in a tidal waterway. All 6 occupants were injured in the accident, the pilot and one skydiver seriously. The aircraft sustained serious damage.

As a result of the accident, the Australian Parachute Federation provided one mandated and a number of recommended safety actions to the aircraft operator which included: mandatory use of restraints below 1,000 ft above ground level; changes to the operator's flying operations manual to include roles and responsibilities of key personnel; increased training requirements and an expanded emergency procedures section.

This accident highlights the risks associated with engine failures at low altitudes.

On 29 September 2011, a Robinson Helicopter, R22 Beta II helicopter (R22), registered VH-RTB, was conducting aerial stock mustering operations about 43 km east-south-east of Maningrida, Northern Territory.

While guiding a herd of buffalo into the yarding area, at about 20 ft above ground level, the helicopter's tail rotor struck a tree. The helicopter landed heavily and sustained serious damage.

This accident not only highlights the challenging nature of aerial stock mustering operations, but also the benefits of utilising resources such as a ground support teams, when operating within the yarding area.

Safety summary

What happened

On 1 October 2011, the pilot of a Morgan Aero Works Cheetah Sierra 200 aircraft (Sierra), registered 24-7634, was attempting to land at the Old Bar Airstrip after conducting a private flight from Taree Airport, New South Wales.

The pilot commenced a go-around after touching down. During the climb out the aircraft collided with a ferris wheel that was part of a group of amusements located at a beach festival, adjacent and to the south of the airstrip.

There were two persons on board the Sierra and four occupants of the ferris wheel at the time of the collision. There were no reported injuries from the occupants of the ferris wheel, and the passenger in the Sierra reported receiving a minor injury.

What the ATSB found

The ATSB found that the management of risk in relation to flight training operations by Recreational Aviation Australia Incorporated (RA-Aus) was adequate; however, it had been circumvented in a number of areas during the training of the pilot. That resulted in a pilot operating in the aviation environment who did not possess the required competencies to exercise the privileges of a private pilot certificate.

The ATSB also found that the approach to the management of risk by the Old Bar Beach Festival Committee, specifically relating to aviation operations at the beach festival, was ineffective and resulted in a level of risk that had the potential to impact on the objectives of the festival.

What's been done as a result

RA-Aus have taken steps to ensure that the flight training facility that undertook the pilot’s training and its staff are aware of the requirements imposed upon them by the RA-Aus Operations Manual, and that RA-Aus staff at the facility have the required skills and knowledge to carry out flight training operations. The pilot underwent a flight review that established the need for additional training.

The festival and airstrip committees reported that in future the airstrip will be closed and aviation operations suspended when the festival is taking place.

Safety message

The management of risk in aviation requires diligence and structure to be effective. In particular, when aviation activities are part of a public event the supporting procedures, processes and guidelines need to be carefully developed and applied to manage risk to those choosing to participate in the aviation environment and to others external to the aviation activity.

Safety summary

What happened

On 29 September 2011 at 1240 Central Standard Time, a Gippsland Aeronautics GA-8 Airvan, registered VH-AJZ, departed Marree, South Australia with one pilot and six passengers for a scenic charter flight over Lake Eyre and surrounding regions. About 45 minutes after take-off and while flying at a height of about 500 ft above ground level the pilot felt a shudder through the airframe, then heard a loud pop and the propeller stopped. The pilot carried out a successful forced landing on the Birdsville Track, approximately 135 km north-north-east of Marree.

What the ATSB found

The No. 5 piston of the aircraft’s single engine sustained a fatigue failure, resulting in severe mechanical damage that stopped the engine. The engine’s oil system was contaminated by metal chipping (spalling) from the bodies of two tappets because of contact fatigue to the tappets. This increased the risk of abnormal wear and failure of pistons and other engine components. The ATSB could not conclusively establish that this led to the piston failure, although similar failures in comparable engines had been attributed to that mechanism.

Although there was little warning to the pilot during flight of the impending engine failure, the operator had recently noted an abnormally high consumption of engine oil, which could have indicated poor engine condition. The oil consumption in fact exceeded the manufacturer’s limits for continued operation, but was misinterpreted, when referred to the maintenance organisation, as falling within those limits.

Finally, there was severe spline wear on the engine-driven fuel pump (EDFP) drive which could, if undetected, have led to EDFP drive failure and sudden loss of fuel flow to the engine, although this did not contribute to the occurrence.

What has been done as a result

The engine manufacturer had previously introduced a factory-fitted roller tappet to reduce spalling. Subsequently, for engines not yet incorporating that modification, the manufacturer introduced a flat tappet with an improved bonded coating, providing a more resilient sliding surface.

The aircraft operator reviewed the circumstances of this occurrence and has improved their monitoring of engine operating data, including oil consumption. 

Accelerated and abnormal EDFP spline wear in this engine type has been subject to ongoing study by the Civil Aviation Safety Authority (CASA). A number of failed EDFP shafts were examined by the ATSB in support of the CASA study.

Safety message

The investigation highlights the importance of operators monitoring and using engine oil consumption data as a diagnostic tool and of immediately investigating oil consumption figures that fall outside the manufacturer’s acceptable limits. Also highlighted are the importance of the engine manufacturer’s recommended oil filter inspections during scheduled maintenance and the associated guidance material when assessing any debris or contamination found.

What happened

On 26 September 2011 at 1151 Eastern Standard Time, the crew of an Airbus A321 (Airbus) aircraft, registered VH-VWW, received on the aircraft's traffic alert and collision avoidance system (TCAS) a traffic advisory (TA) alert, for an aircraft that was approaching from their front-right position at 2 NM (3.7 km) at 2,700 ft. The Airbus was maintaining 3,000 ft on an ARBEY standard terminal arrival route to runway 34 Left at Melbourne Airport, Victoria and was in Class C controlled airspace. The upper limit of non-controlled Class G airspace in the area was 2,500 ft.

It was later found that the pilot of the other aircraft a Piper PA-28-181 Archer, registered VH-TXD, had incorrectly set the aircraft's altimeter barometric pressure subscale setting, resulting in the aircraft entering controlled airspace without a clearance and a violation of controlled airspace occurring.

The occurrence was quickly resolved due to the traffic alert from the Airbus A321 aircraft's TCAS and the subsequent response from the flight crew.

This incident acts as a reminder to pilots of the importance to cross-check cockpit settings before flight.

What happened

At about 1142 Eastern Standard Time on 26 September 2011, two Beech A36 (Bonanza) aircraft, registered VH-IOL (IOL) and VH-YEN (YEN), operating under the Visual Flight Rules in G airspace, came into close proximity near Ravensworth, New South Wales, at 2,700 ft above mean sea level. The pilot of IOL was successfully alerted by Brisbane air traffic service (ATS), in time to see the other aircraft and initiate an avoidance manoeuvre. The pilot of YEN had not been monitoring that radio frequency and never saw the other aircraft. IOL was equipped with a portable collision avoidance system, but the pilot had switched it off because of ground-based machinery interference.

The chance of a successful avoidance manoeuvre was increased because one of the pilots had been successfully alerted by ATS. The alert occurred because both aircraft had transponders active on Mode C, enabling ATS to be aware of the proximity between the two aircraft.

The incident highlights the safety benefits for pilots to maintain an active listening watch on the appropriate radio frequency. Traffic information from any source can direct the attention of pilots to help them 'see-and-avoid' other aircraft in the vicinity.