Safety summary

What happened

At 0743 on 20 December 2011, an empty coal train collided with an excavator that was being used for scheduled maintenance of rail lines near the High Street Station at Maitland, NSW.

The excavator suffered extensive damage while the lead locomotive suffered minor damage and was able to continue on its journey after a crew change. Neither the train drivers nor the track workers were injured in the collision.

What the ATSB found

The ATSB found that the collision occurred despite the fact that the maintenance work being undertaken had been authorised and that safety measures designed to exclude rail traffic from the worksite had been put in place.

The ATSB further found that the network control officer did not confirm the location of the worksite before authorising access to the track for maintenance purposes, there were communication protocol omissions between network control and the worksite protection officer and a lack of coordination between interfacing network control officers.

What has been done as a result

The track manager has advised that it is reviewing the safe working rules and will include the issues identified by the ATSB in that review.

Safety message

The incident highlights the importance of ensuring the exact location of a given worksite is clearly understood by all concerned in providing protection and that communications between network control officers and worksite staff is effective.

Safety summary

What happened

On 15 December 2011, British Beech was berthed in Brisbane, Queensland, and its crew was taking on stores from a barge. During the return of a stores container from the ship to the barge, the container came free of its slings. It fell to the barge below, striking the master of the barge. The master was attended to by the barge crew and shore paramedics but he died from his injuries while being transported to hospital.

What the ATSB found

The ATSB found that the container had not been appropriately rigged on board the ship and the ship’s crew had not warned the barge crew of its return. The ship’s crew did not view the storing operation as dangerous and had, over time, removed identified safety barriers which would probably have prevented the accident. Compliance auditing processes had not identified and minimised such routine violations of the shipping company’s procedures.

The ATSB also found that the barge master had placed himself in a position of danger under the suspended load, and that the barge crew had not followed their company’s procedures for storing operations. The ATSB further found that the company had not adequately implemented compliance auditing or incident reporting schemes. As a result, the company had not acted on, or learnt from, previous less serious incidents.

What has been done to fix it

The method used for handling containers of this type in Brisbane has been altered so that the containers are top lifted and slings are no longer used.

The ship’s manager, BP Shipping, implemented a requirement to have the lifting point fixed and above the centre of gravity of loads. A thorough review of lifting and slinging processes, practices, procedures and equipment was conducted as well as a review of lifting and slinging job hazard analyses. A fleetwide review and training workshop for lifting and slinging was also completed.

The barge’s operator, Bowen Tug and Barge, undertook a review of its operations and work practices. On 1 July 2012, the company ceased ship storing operations and sold all associated vessels and equipment to another operator.

Safety message

Lifting operations, even when they are routine, involve inherent risks. Therefore, established procedures must be followed, reinforced and audited to ensure vigilance is maintained and complacency avoided. The basic precaution of standing well clear of suspended loads must always be taken.

While attempting a take-off from an improvised runway at about 1800 Eastern Daylight-saving Time on 15 December 2011, an Auster Aircraft Ltd J5F (Auster), registered VH-AFT (AFT), failed to climb sufficiently to clear a fence in a paddock 1 km south of Tyabb aeroplane landing area (ALA), Victoria. The aircraft was seriously damaged when it came to rest inverted. The owner-pilot, the only occupant, received minor injuries.

The pressure perceived by the pilot to get the aircraft back to Tyabb may have led him to make the decision to take-off in less than ideal circumstances. An earlier successful forced landing may also have contributed to the accident in that it boosted the pilot's confidence in his ability to retrieve the aircraft from the paddock.

This accident highlights the need for pilots to be aware that pressure can come about for a variety of reasons, and of the importance of understanding one's personal limitations. By making decisions pre-flight, being mindful of pressures and by setting and sticking to personnel minimums, pilots can reduce the risk of being involved in an accident.

Prior to conducting any unusual operation, a pilot should carefully consider all options and seek the most accurate information available. Threat and error management (TEM) training has the potential to provide significant safety benefits to the general aviation (GA) community.

At about 0349 Eastern Daylight-saving Time, the Melbourne aerodrome controller cleared an Emirates Airlines, Boeing Company 777-31H/ER aircraft registered A6-EGG for take-off on runway 16.

The crew believed that the runway lights were on a low setting and conducted the take-off. Once airborne the pilots advised the approach controller that they believed that the lights were on a low intensity. A subsequent check of the airport lighting system revealed that runway 16 lights were turned off.

Had the crew queried the status of the runway lights, the aerodrome controller would have been able to identify that they had not been turned on as believed and corrected the situation.

This incident highlights the potential hazards associated with skill based human error and the need for increased vigilance when working in isolation in a safety critical environment.

Airservices Australia, advised the ATSB that they were in the process of standardising the operation of runway lighting controls at Towers and would propagate a national ATC instruction pending the related change effective 28 June 2012.

Aviation Short Investigation Bulletin - Issue 11

On 9 December 2011 a S.O.C.A.T.A. Groupe Aerospatiale TBM 700 aircraft, registered VH-VSV (VSV) departed Bankstown airport, for a private flight to Merimbula, New South Wales. Onboard the aircraft was a pilot and one passenger.

The pilot was cleared to depart Bankstown control zone on a downwind departure from runway 11 left, however mistakenly conducted an upwind departure. The aircraft penetrated Sydney controlled airspace by 2.3 NM and came within 1.2 NM with no vertical separation of another aircraft on approach into Sydney Airport and a breakdown of separation occurred.

The controller at Bankstown tower then instructed the pilot of VSV to conduct a left turn and track back overhead Bankstown airport.

This incident highlights the importance of developing a technique to ensure a clearance is processed, understood and actioned correctly. It is also important to clarify a clearance if any ambiguity exists. Finally, pre-flight planning is essential to ensure safe flight. CASA has published a Visual Pilot Guide for Archerfield, Jandakot, Melbourne, Parafield and Sydney areas to provide detailed assistance for operating in these areas.

What happened

On 7 December 2011, the owner-pilot of a Cessna 210M, registered VH-WBZ, was conducting a private flight under the visual flight rules from Roma to Dysart in Queensland. Thunderstorms with associated cloud, rain and severe turbulence were forecast for the area. About 30 minutes into the flight the outer sections of the wings and parts of the tail separated. The aircraft collided with terrain, fatally injuring the pilot.

What the ATSB found

The ATSB established that the aircraft was structurally sound before the wing and tail sections separated. No aircraft system defects were identified. Ground-based weather radar showed thunderstorms in the vicinity of the accident site, and recorded engine data showed cruise power setting was maintained until recording ceased. Although the precise circumstances leading up to the accident were not known, a combination of aircraft airspeed with the effects of turbulence and/or control inputs generated stresses that exceeded the design limits of the aircraft structure.

Safety message

Airspeed is a critical factor in the stress sustained by an aircraft. Pilots need to be aware of the manoeuvring (V_A) speed for the aircraft weight, and to control the airspeed so as not to exceed that value when full control deflection is required, or severe turbulence or wind/gusts are encountered.

Severe turbulence and wind gusts are just some of the hazards prevalent in and around thunderstorms. This accident is a reminder to all pilots that, to minimise the risk of structural damage or loss of control, thunderstorms should be avoided.

What happened

On 6 December 2011, a Bombardier DHC-8-315 aircraft, registered VH-SBV and operated by QantasLink, was on a scheduled flight from Cairns to Weipa, Queensland. The aircraft was on descent with the power levers in the flight idle position and the first officer’s hand was on the power levers. When the aircraft encountered turbulence, the first officer inadvertently lifted one or both of the flight idle gate release triggers and moved the power levers below the flight idle gate. During the short time that the power levers were in the ground beta range, both propeller speeds increased uncontrollably by over 300 revolutions per minute (rpm). Realising the situation, the first officer immediately moved the power levers back above the flight idle gate and the propellers returned to the normal controlled operating rpm.

What the ATSB found

The aircraft design included features to reduce the likelihood of the power levers being moved below flight idle and into the ground beta mode during flight. However, the ATSB found that many DHC-8-100, -200 and -300 series aircraft did not have a means of preventing inadvertent or intentional movement of power levers below the flight idle gate in flight, or a means to prevent such movement resulting in a loss of propeller speed control. This design limitation has been associated with several safety occurrences.

The ATSB also concluded that the beta warning horn sounded as designed; however, the pilots were not acutely aware of the purpose of the warning horn due to a lack of previous exposure to the sound.

What has been done as a result

The aircraft manufacturer has advised that it will be releasing a Service Bulletin modification to rectify the propeller speed control issue. That bulletin will be mandated by an Airworthiness Directive (AD) from the airworthiness authority of the State of Design (Canada) to ensure that the bulletin is incorporated into all the aircraft affected by the design issue worldwide, including those in Australia. In addition, the aircraft operator has introduced a series of actions to reduce the risk of such occurrences. The ATSB has released an extract from the cockpit voice recorder with the beta warning horn and the audible rise in propeller speed to all Australian operators of the aircraft type and it is also available

Safety message

Until appropriate modifications are made to DHC-8 aircraft, pilots and operators of DHC-8-100, -200 and -300 series aircraft should familiarise themselves with the circumstances surrounding this occurrence and take the appropriate steps to minimise the possibility of propeller overspeed due to ground beta selection in flight.

On 6 December 2011, a Rockwell International 114 (Commander), registered VH-SJF (SJF), made a planned refuelling stop at Meekatharra Aerodrome in Western Australia on a flight from Karratha to Perth. Immediately following the refuel, the pilot taxied for departure before an approaching storm cell arrived in the area.

Shortly after rotation at 0925 WST, the wind speed and direction changed suddenly, causing the aircraft to sink and drift off the runway. The pilot initially lowered the nose, but then raised the nose and applied power to clear a ditch and mound running parallel to the runway.

The pilot again lowered the nose, but as the aircraft was not developing sufficient lift to clear trees ahead, he cut the power and aimed for a gap in the trees. The left wing contacted a tree and spun the aircraft, causing serious damage. The pilot, who was the sole occupant, was uninjured.

Weather related issues accounted for 25% of local condition related safety factors identified in aviation investigations completed by the ATSB over the 2010-11 period.

An ATSB aviation research and analysis report published in 2010 found that private operations accounted for 44% of accidents in proportion to hours flown. Problems with a pilot's assessment and planning were evident in all of these accidents. The report recommended that private pilots make decisions pre-flight and that they set and stick to personnel minimums.

Wind direction and strength can change ahead of a storm cell. The Pilot's Handbook of Aeronautical Knowledge, published in 2008 by the Federal Aviation Authority (FAA), described the impact of windshear, specifically a microburst, on an aircraft taking off. The description in the Handbook matches the sudden change in wind and aircraft performance characteristics reported by the pilot.

On 5 December 2011, at about 1030 EDT a Taylorcraft model BC12-D aircraft, registered VH-PEE, was engaged in taxi trails as part of a pre-flight inspection for a flight scheduled late in the day. The pilot reported that, while using a grass runway, 26 km to the south-east of Gunnedah Aerodrome, NSW the aircraft was struck by a strong wind gust or Willy-willy and, on attempting to correct with engine power and right rudder, the aircraft veered off of the runway. He was unable to regain control, and the aircraft subsequently struck a fence on the northern side of the runway and flipped over, coming to rest inverted. There were no injuries to the pilot. The aircraft incurred serious damage which included damage to the propeller, one wing strut and the wing surfaces.

Past studies have indicated that Willy-willies are unseen, unpredictable and can adversely affect light aircraft and helicopters when they are operating on or close to the ground. Pilots must be vigilant when operating in these areas and be prepared to react to mitigate the effects of Willy-willies and maintain control of the aircraft.

During the afternoon of 5 December 2011, an instructor and student were conducting emergency procedures training in the circuit at Moorabbin aerodrome, Victoria, in a Schweizer 269C-1 helicopter, registered VH-XTY. The flight was to include low-level autorotations to simulate an engine failure during the take-off and approach.

At about 1520 Eastern Daylight-saving Time, and at about 200 ft above ground level (AGL), the instructor initiated a practice engine failure after take-off. The exercise was to be conducted to a power termination.

The student entered autorotation and subsequently flared the helicopter to the instructor's satisfaction; however, the helicopter did not decelerate as expected. Realising that imminent ground contact would be excessive; the instructor took control, levelled the skids and attempted to arrest the descent. The helicopter impacted the ground heavily in a level attitude, moving forward and with the skids straight. The helicopter subsequently rolled onto its left side and was seriously damaged. The instructor received minor bruising and the student was uninjured.

While the reason for the accident could not be conclusively established, it is possible that low forward airspeed was a contributory factor.

As a result of this occurrence, the aircraft operator has advised the ATSB that they are reviewing their procedures for the conduct of low-level autorotations.