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.

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.

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.

Preliminary report released 21 April 2011

The information contained in this Preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the ongoing investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this Preliminary report. As such, no analysis or findings are included in this report.

Abstract

At 1209 on 24 February 2011 a suburban passenger train (215A) with 17 passengers on board was being routed from the Up South Main Line into number 5 platform at the Adelaide Railway Station. At about the same time a second passenger train (G231) with 22 passengers on board that was departing the Adelaide Railway Station passed signal 141 located at the end of number 3 platform at low speed. The signal was displaying a stop (red) indication.

A short time later the drivers of both trains realised that they would come into conflict and applied their train's brakes, too late to avoid a collision. There were no injuries as a result of the collision but both trains sustained minor damage.

The investigation is continuing

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.

Preliminary report released 2011

The information contained in this Preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the ongoing investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this Preliminary report. As such, no analysis or findings are included in this report.

Abstract

At about 0618 on Thursday 25 November 2010, freight train 4DA2, operated by FreightLink Pty Ltd, derailed on the Central Australian Railway line just 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 renewal.

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 15 February 2011, the ATSB commenced an investigation into a pre-flight planning event that occurred at about 0017 Eastern Daylight-saving Time on 11 February 2011 and involved an Airbus A320-232 aircraft, registered VH-VNB. The initial report from the operating crew was that, prior to departure on the scheduled high capacity flight from Melbourne, Victoria to Perth, Western Australia, incorrect data was entered into the aircraft's flight management computer. The suspected 'error' was not detected by one of the flight crew until the aircraft was in the take-off roll. Subsequently, the second member of the flight crew reported that the speeds that were used were correct and were logical for the aircraft's weight and ambient conditions.

An initial examination of the available recorded data showed a consistent acceleration, rotation and climb with no abnormalities. The recorded speed at rotation correlated with that used for the flight and noted on the aircraft's data card. No equipment anomaly was recorded in the aircraft's technical log after the flight.

The ATSB's primary focus is on enhancing safety with respect to fare-paying passengers and, in particular, those transport safety matters that may present a significant threat to public safety or are the subject of significant public concern. In this instance, the contrasting flight crew recollections of the 'event' and the available data suggest that a transport safety matter as defined in Section 23 of the TSI Act may not have taken place.

The ATSB therefore considered there was limited potential to enhance transport safety by continuing this investigation, and has elected to discontinue it. However, the data already collected may be used by the ATSB for future statistical analysis and safety research purposes.

Abstract

On 2 February 2011, the boatswain (bosun) on board the Panamanian registered bulk carrier Hanjin Sydney died as a result of injuries he received after falling about 25 m from the hatch coaming of the ship's number eight cargo hold to the tank top below.

The bosun had climbed onto the top of the hatch coaming to free a cargo runner that had jammed in the head of a davit the crew were using to lift iron ore residue from the hold. He lost his balance while pulling on the wire to free it and fell into the empty cargo hold.

The ATSB investigation found that the crew had previous experience with the cargo runner jamming in the head of the davit. However, nothing had been done to prevent it from happening again.

As a result of the accident, Hanjin Ship Management have instigated the requirement for the ship's safety officer to be more proactive in toolbox meetings and safety 'walk arounds' to ensure that he is aware of issues which may not be automatically brought to his attention.

The ATSB is satisfied that this safety action adequately addresses the report's identified safety issue.

On 9 February 2011, a Piper PA-28-181 (Archer) aircraft, registered VH-NRF, departed Ballina on a private flight to Bankstown, New South Wales.

During the flight, the pilot noted the tachometer fluctuating. After consultation with the operator, it was determined that this was an indication problem, and the flight was continued.

When the aircraft was about 8 km NE of Bankstown at 1,200 ft, the engine lost power. The pilot commenced the engine failure response actions and elected to land on a street. During the landing the aircraft collided with powerlines and a power pole. The pilot and passenger sustained minor injuries.

It was considered that the engine failed as a result of fuel starvation. The reason for the tachometer fluctuation was not identified.

The operator conducted an investigation and considered that, as no apparent fuel leaks were found, the aircraft may have experienced excessive fuel burn.

As a result of this accident, the aircraft operator issued an internal circular to all instructors to emphasise to students the importance of fuel tank selection changes when responding to an engine failure; amended their operations manual with regard to fuel mixture leaning, and the use of fuel gauges and calibration cards; included the recording of fuel uplifted at the end of each flight so that accurate fuel flow calculations can be conducted; and a student pilot meeting was held to highlight this accident and the changes to the operations manual.

This accident highlights the risks associated with operating an aircraft that has different procedures from that previously familiar with and the importance of having accurate knowledge of the aircraft's fuel usage.

Preliminary report released 18 March 2011

On 4 February 2011, a Robinson Helicopter Company R44 Astro helicopter (R44), registered VH‑HFH, was conducting circuit operations at Cessnock Aerodrome, New South Wales. On board the helicopter were an instructor, a pilot undergoing a helicopter flight review and a passenger.

Following the completion of a sequence involving the simulated failure of the helicopter's hydraulic‑boost system, the instructor assessed that the hydraulic system had actually failed. He elected to reposition the helicopter on the aerodrome to facilitate further examination. Upon becoming airborne, control of the helicopter was lost, and it collided with the runway and, shortly after, there was a fire. The pilot managed to exit the helicopter; however, the instructor and passenger were fatally injured.

Examination of the wreckage identified that a bolt securing part of the flight control system had detached. Although the circumstances of the accident are still under investigation, the Australian Transport Safety Bureau has, in the interest of transport safety, issued a Safety Advisory Notice suggesting that operators of hydraulic system-equipped R44 helicopters, and organisations performing inspection, testing, maintenance and repair activities on the flight controls of those helicopters, inspect and confirm the security of the aircraft's hydraulic-boost servos.