Abstract

At about 2031 on Wednesday 30 March 2011 a southbound Port Kembla to Parkes empty bulk grain train experienced a train parting event at about the 285-track kilometre point near Gunning (Oolong), NSW, on the down main Sydney to Melbourne rail line. There were no injuries or damage as a result of the incident.

Preliminary report released on 30 March 2011

This preliminary report details factual information established in the investigation’s early evidence collection phase and has been prepared to provide timely information to the industry and public. Preliminary reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.

On 5 February 2011, the pilot of a Cessna 310R aircraft, registered VH-XGX, was conducting a return flight to Darwin, Northern Territory, following a charter flight to Bathurst Island, Northern Territory.

The pilot departed from Bathurst Island Aerodrome at approximately 2140 Central Standard Time and the aircraft collided with terrain shortly thereafter - approximately 1 km from the upwind end of the departure runway.

The pilot, the sole occupant of the aircraft, sustained fatal injuries and the aircraft was destroyed by the impact forces and a post-impact fire.

On 25 March 2011, a Cessna 172 aircraft, registered VH-SMY, departed Geraldton on a charter passenger flight to East Wallabi Island (in the Abrolhos Islands group), Western Australia.

While on final approach to the Island, the nose of the aircraft was positioned at a 45° angle to the runway to remain aligned with the centreline due to gusty winds. The wind conditions appeared to be from an east to south-easterly direction. When at about 500 ft the pilot elected to overfly the runway.

A second approach was commenced, but the wind was again too strong for a landing with a go-around conducted. Despite full power being applied the engine did not perform as expected during the climb for another circuit.

During downwind, the pilot noted that the windsock was moving considerably. On final, the aircraft was again at a 45° angle and experiencing wind buffet.

During the landing flare, the aircraft floated, before touching down about halfway along the runway. Determining the aircraft could not be stopped by the runway end, the pilot elected to go-around. He moved the throttle full forward, but the engine did not deliver full power. The aircraft momentarily became airborne before contacting a sand dune and coming to rest upright in the water.

The pilot reported that, due to the recent commencement of his employment with the operator, he wanted to complete the flight.

This accident highlights the need for pilots to be aware that self-imposed undue pressure, can come about for a variety of reasons (time or task-oriented). It is important to understand one's personal limitations, especially when flying in or around adverse weather conditions.

On 22 March 2011, an Airbus Industrie A330-203 aircraft, registered VH-EBL, was being operated by Qantas Airways, on a scheduled flight from Manila to Sydney, New South Wales. At about 365 NM (676 km) northwest of Cairns, at 39,000 ft, a smell became noticeable on the flight deck and the passenger cabin. The flight crew actioned the aircraft quick reference handbook checklist for Smoke/Fumes/Avionics which removed the odour.

Following electrical arcing of the left windshield heater, a small flame appeared from the bottom left corner of the captain's windshield. The crew donned oxygen masks and extinguished the flame using the cockpit BCF fire extinguisher. There were about four more occasions when arcing and flames appeared and were extinguished. The crew advised air traffic control (ATC) that due to a technical issue they would be diverting to Cairns. The crew also advised ATC that they had extinguished repeated fires as a result of electrical arcing in the captain's windshield heater. ATC declared an INCERFA. The captain advised that emergency services were not required but would advise if the situation changed. The aircraft completed an uneventful landing at Cairns a short time later and the INCERFA was cancelled.

Due to similar reported events, the aircraft operator had in place a windshield replacement program, with a projected completion date for the replacement of identified windshields, by the end of September 2011. This was well within the Airbus Industrie compliance date of May 2012.

On 8 March 2011, an Eastern Australia Airlines operated (the operator) Bombardier Inc. DHC-8-315 aircraft, registered VH-SBI, departed Melbourne, Victoria on a scheduled passenger service to Devonport, Tasmania.

On arrival at Devonport, a runway 24 area navigation global navigation satellite system (RNAV (GNSS)) approach was commenced. The crew did not become visual with the runway at the minima due to the prevailing weather conditions and a missed approach was conducted. The aircraft was climbed to 3,100 ft and a holding pattern conducted.

A second approach was commenced, during which time, the aircraft's speed decayed. The pilot in command (PIC) made two airspeed advisory calls and the copilot responded immediately by increasing power on each occasion. The two power applications failed to accelerate the aircraft, and the crew observed the airspeed reduce to 107 kts. The PIC called assertively for more power to be applied, and the copilot immediately responded by applying power. During the recovery, the aircraft's engines were over-torqued to 120% for about 2 seconds. The operator and engine manufacturer transient over-torque limits were not exceeded.

A second missed approach was conducted, and the flight was diverted to Launceston, Tasmania where the aircraft landed without further incident.

In response to this incident, and a stickshaker warning event involving a Eastern Australian Airlines Bombardier Inc. DHC-8-315 aircraft on 1 March 2011 (ATSB investigation AO-2011-036), the operator issued a safety alert stating that the primary consideration for pilots is to maintain an awareness of the aircraft's speed, altitude and position; and controlling its flight path.

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.

Discontinued:

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.

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.

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.

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.