At about 0840 on 17 March 2011 a Track Occupancy Authority (No50A) was issued from 09-13 signal Stroud Road to 11-03 signal South Craven for a hi-rail weed sprayer to work on track. At 0851 the Protection Officer advised the Network Controller that he was in the Stroud Road to Craven section at 283.084 km (which is near Wards River @ 282.783 km) and was about to put the hi-rail on the track when he realised a train was approaching. No person was injured and there was no damage.

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 17 March 2011, the ATSB commenced an investigation into a safeworking irregularity incident that occurred at about 0840 Eastern Daylight-saving Time on 17 March 2011 near Wards River, New South Wales.  Examination of the information collected during the investigation identified that the occurrence had significant similarities to aspects of another occurrence already being investigated by the ATSB. That investigation, RO-2010-004, involved a collision between an XPT passenger train and a track-mounted excavator near Newbridge, New South Wales on 5 May 2010.

Given the similarity of the two occurrences, the ATSB has decided to examine the Wards River occurrence within the RO-2010-004 investigation of the accident at Newbridge. Accordingly, the separate RO-2011-005 investigation of the Wards River occurrence was discontinued.

What happened

On 3 March 2011, an Aero Commander 500-S aircraft, registered VH-WZI, departed Horn Island for Cairns, Queensland on a charter flight with one pilot on board. The purpose of the flight was to transport live crayfish.

The aircraft was about 56 NM (104 km) north of Cairns when the pilot reduced the power to slow the aircraft for operational reasons. Following the reduction in power, the pilot observed a reduction in performance in the right engine, which he believed was due to a fuel blockage.

The pilot was unable to clear the blockage and declared a mayday. He elected to descend towards the coastline away from high terrain as the aircraft was unable to maintain height. The right engine was shut down and the right propeller feathered after the aircraft was clear of high terrain. The aircraft was diverted to Bloomfield River aeroplane landing area.

As a result of this incident, the operator advised the ATSB that they have amended their planned flight route from Horn Island to Cairns, with aircraft now required to track via Cooktown to remain clear of high terrain. The operator also informed all of their safety critical personnel about the incident and has ensured they are aware of fuel blockage issues with the Aero Commander.

Abstract

On 1 March 2011, a QantasLink Bombardier Inc DHC-8-315, registered VH-TQL, was conducting a regular public transport flight from Tamworth Airport to Sydney Airport, New South Wales. The crew were conducting a Sydney runway 16 left (16L) area navigation global navigation satellite system (RNAV(GNSS)) approach in Vertical Speed (VS) mode. The aircraft's stick shaker stall warning was activated at about the final approach fix (FAF). The crew continued the approach and landed on runway 16L.

The stick shaker activated at a speed 10 kts higher than was normal for the conditions. The stall warning system had computed a potential stall on the incorrect basis that the aircraft was in icing conditions. The use of VS mode, as part of a line training exercise for the first officer, meant that the crew had to make various changes to the aircraft's rate of descent to maintain a normal approach profile.

On a number of occasions during the approach the autopilot pitched the aircraft nose up to capture an assigned altitude set by the pilot flying. The last recorded altitude capture occurred at about the FAF, which coincided with the aircraft not being configured, the propeller control levers being at maximum RPM, and the power levers at a low power setting. This resulted in a continued speed reduction in the lead-up to the stick shaker activation.

Each factor that contributed to the occurrence resulted from individual actions or was specific to the occurrence. The Australian Transport Safety Bureau is satisfied that none of these safety factors indicate a need for systemic action to change existing risk controls. Nevertheless, the operator undertook a number of safety actions to minimise the risk of a recurrence.

In addition, the occurrence highlights the importance of effective crew resource management and of the option of conducting a go-around should there be any doubt as to the safety of the aircraft. Transport Canada, which regulates the aircraft manufacturer, advised that it will publish a summary of this occurrence and recommend that operators consider using it in their scenario-based crew resource management training programs.

Abstract

On 24 February 2011 and 3 November 2011 respectively, two different Airbus A380-842 (A380) aircraft were being operated by Qantas Airlines on scheduled passenger services from Singapore to London, United Kingdom.

About 8 hours into the flight on 24 February 2011, the flight crew detected a reduction in the indicated oil tank quantity for the No 3 engine. The crew reduced the thrust on the affected engine to idle and continued to the planned destination. Maintenance personnel found that one of the engine's external oil feed pipes was finger tight and had leaked. This was the fourth event involving similar in-flight oil loss from engines installed on the operator's fleet of A380 aircraft.

Examination and testing by the engine manufacturer found that the oil leaks were the result of a loss of clamping force on the oil feed pipe connection at the engine casing. Potential factors in the loss of clamping force were identified and were subject to ongoing engineering analysis. In the interim, the aircraft operator checked the engine oil feed pipes every five flight cycles, then every 20 cycles for evidence of oil leakage.

On 3 November 2011, a different aircraft was about 3 hours into the flight when the flight crew received a low oil quantity advisory for the No 4 engine. Forty minutes later, the crew received a low oil pressure warning from that engine. The crew shut down the engine and diverted the aircraft to Dubai, United Arab Emirates. Maintenance personnel found that one of the engine's oil feed pipes had leaked in the same location as the earlier A380 engine oil loss events.

By the time the November event occurred, there had been 15 engine oil leaks across the A380 fleet worldwide. The engine manufacturer conducted an ongoing investigation into the oil leaks and at the time of writing this report had identified high pipe deflection loads as a significant factor. Subsequent action by the engine manufacturer included modification of the oil pipe clipping arrangement and revised securing methods for the pipe connection and deflector assembly. In addition, trend monitoring of engine oil consumption was enhanced and work continued to develop a new oil pipe design.

Abstract

At about 1028 (Eastern Daylight Saving Time) on Friday 25 February 2011, a southbound Brisbane to Melbourne freight train passed the home signal at Yerong Creek at red (Stop) without authority. Yerong Creek is about 387 km from Melbourne and 565 km from Sydney on the main Sydney to Melbourne rail line. There were no injuries or damage as a result of the incident.

Safety summary

What happened

At 0445 Eastern Standard Time on 24 February 2011, the pilot of an Aero Commander 500S, registered VH-WZU, commenced a freight charter flight from Cairns to Horn Island, Queensland under the instrument flight rules. The aircraft arrived in the Horn Island area at about 0720 and the pilot advised air traffic control that he intended holding east of the island due to low cloud and rain. At about 0750 he advised pilots in the area that he was north of Horn Island and was intending to commence a visual approach. When the aircraft did not arrive, a search was commenced but the pilot and aircraft were not found. On about 10 October 2011, the wreckage was located on the seabed about 26 km north-north-west of Horn Island.

What the ATSB found

The ATSB found that the aircraft had not broken up in flight and that it impacted the water at a relatively low speed and a near wings-level attitude, consistent with it being under control at impact. It is likely that the pilot encountered rain and reduced visibility when manoeuvring to commence a visual approach. However, there was insufficient evidence available to determine why the aircraft impacted the water.

Several aspects of the flight increased risk. The pilot had less than 4 hours sleep during the night before the flight and the operator did not have any procedures or guidance in place to minimise the fatigue risk associated with early starts. In addition, the pilot, who was also the operator’s chief pilot, had either not met the recency requirements or did not have an endorsement to conduct the types of instrument approaches available at Horn Island and several other locations frequently used by the operator.

What has been done as a result

Following the accident, the operator ceased operations and did not have the opportunity to enhance its processes.

Separately, and although not undertaken as a result of the accident, in May 2012 the Civil Aviation Safety Authority (CASA) issued a notice of proposed rulemaking relating to flight crew fatigue management. In the case of single pilot public transport operations, this included a proposal to restrict the duration of a flight duty period and the number of late-night duty periods in certain circumstances. In addition, in July 2012 CASA issued draft requirements for the installation of additional equipment in small aircraft involved in passenger transport operations, such as a terrain awareness and warning system and weather radar equipment.

Safety message

Although no firm conclusions could be drawn regarding why the aircraft impacted the water, the ATSB highlights the need for pilots to ensure they have had sufficient sleep prior to conducting a flight, and that operators have processes in place to manage the potential fatigue risks, including those associated with early starts.

What happened

On 9 February 2011, a Cessna 210L aircraft, registered VH‑AQS, departed Temora, for a local low-level survey flight in the vicinity of Junee and Cootamundra, New South Wales.

The survey flight was conducted at 133 ft above ground level. About 1 hour and 20 minutes into the flight, the aircraft struck a powerline, which was strung across a 907 m span over a gully.

Following the collision with the powerline, the pilot diverted to Cootamundra aerodrome and conducted a flapless approach and landing. The pilot reported that the aircraft did not have any control issues following the wirestrike.

As a result of the investigation, the operator has issued a memo to flight crew highlighting the details of the event. The operator has also raised the minimum survey height to 180 ft for high-risk survey tasks and will roster more experienced crews on these jobs.

The operator's Chief Pilot has also reiterated to pilots that they are encouraged to raise the survey height if they believe a safety hazard exists.

Executive summary

At 1209 on 24 February 2011 a suburban commuter train (215A) with 17 passengers on board was being routed from the Up South Main Line into platform 5 at the Adelaide Station. At about the same time a second commuter train (G231) with 22 passengers on board that was departing the Adelaide Station passed signal 141 located at the end of platform 3 at low speed. Shortly thereafter both drivers realised that their trains would come into conflict and applied their train brakes but it was too late to avoid a collision. There were no injuries as a result of the collision; however, both trains sustained minor damage.

The ATSB established that the driver of train G231 received a 'yellow' Right of Way flag from the Platform Coordinator, indicating that platform work was complete and that the train could advance up to signal 141 which was displaying a stop (red) indication.

It was concluded that as the train approached signal 141 the driver diverted his attention onto a lesser task of checking train notices and did not concentrate on the more important task of observing the status of signal 141. Subsequently he perceived that signal 141 had changed to a 'proceed' aspect, although the investigation subsequently established that it did not clear at any stage prior the SPAD event and continuously displayed a stop (red) indication for the passage of train G231.

In the interests of enhancing future rail safety the ATSB identified a number of safety issues which included the dispatching of trains towards starting signals, the level of protection afforded by the train's dead man's control and Automatic Warning System and a range of opportunities to reduce the risk of human performance error. The ATSB is satisfied that the actions proposed in response by Public Transport Services adequately address each of the safety issues.

What happened

On 16 February 2011, a Piper Aircraft Corporation PA-30 aircraft, registered VH-MAC, was being operated on a private flight from Coldstream, Victoria, to Canberra, Australian Capital Territory, via Strathbogie, Wangaratta Vic. and Albury, NSW, under the instrument flight rules. On board the aircraft were the pilot and one passenger. In preparation for the flight, the pilot had submitted a flight plan and obtained an aviation meteorological area forecast the previous evening.

After departure from Coldstream aerodrome, the pilot obtained clearance to 9,000 ft above mean sea level. While flying in light cloud and passing NE of Albury, tracking to Canberra, the aircraft encountered severe turbulence. After experiencing uncommanded climbs and descents continuously for nearly 35 minutes, while at times becoming inverted, the pilot saw terrain through a break in the cloud and flew clear of the cloud. The pilot then decided to divert to Albury and landed safely a short time later.

The pilot stated that in future, he would check the aviation area forecast prior to departure.

Abstract

At about 0618 on Thursday 25 November 2010, freight train (4DA2) operated by FreightLink Pty Ltd derailed on the Central-Australia Railway line, near the 826 km mark, about 5 km south of Cadney Park in South Australia.

There were no injuries as a result of the derailment but there was significant damage to rolling stock and about 300 m of track required replacement.

The investigation determined that a severe weather event, very strong winds associated with thunderstorm activity, were of a sufficient magnitude to initiate the rollover and subsequent derailment of a group of lightly loaded double-stacked container wagons.

A number of minor safety issues were identified as a result of the investigation and have been brought to the attention of Genesee & Wyoming Australia Pty Ltd (GWA). These issues primarily relate to the wind effect on lightly loaded/high vehicles (particularly double-stacked containers) and the identification of and response to severe weather events.