On 23 October 2010, the student pilot of a Cessna Aircraft Company 152, registered VH-HCC (HCC) was conducting solo circuit training at Bankstown aerodrome, New South Wales (NSW). At the same time, a flying instructor and student pilot were conducting dual training circuits in a Piper Aircraft Corporation PA-28-161, registered VH-XSN (XSN).

While on the base leg of the circuit, the pilot of HCC reported sighting another aircraft at a 90^º angle to his right. He noted that this aircraft was a long way from the aerodrome and decided to continue flying his circuit as normal. At the same time, when on final for runway 29L, the student pilot of XSN observed a Cessna 152 aircraft turn in front, and below his aircraft. The instructor initiated a go-around and advised air traffic control (ATC).

The distance between the two aircraft was estimated at 100 m horizontally and 100 ft vertically.

It is important that pilots apply the principles of 'see-and-avoid' by maintaining a constant lookout for other traffic in the circuit and actively listen to the radio to ensure that separation with preceding aircraft is maintained. If there is any doubt as to the position of other aircraft, contact ATC or make a broadcast.

On 23 October 2010, a De Havilland Canada DHC-2 MK 1 floatplane, registered VH-PCF, was being operated on a charter passenger flight from Green Island to Cairns, Queensland.

During the take-off, the pilot applied right rudder to counteract the aircraft's engine torque component and right aileron to compensate for the crosswind. Immediately after becoming airborne, the aircraft began turning to the left. The pilot rejected the take-off and the aircraft landed heavily, sustaining serious damage. The pilot could not recall if the aircraft had encountered a gust of wind after becoming airborne.

Shortly after, a boat arrived from Green Island and the passengers were assisted to shore. None of the aircraft occupants received injuries.

At the time of the accident, the wind conditions experienced at Green Island were close to the maximum operational limitations stipulated by the aircraft operator.

This accident is a reminder of the challenging conditions that pilots operating in an open water environment may be faced with. It is crucial that pilots have an appreciation of the existing wind conditions prior to the take-off, and in the event of unexpected wind gusts during the take-off, the pilot responds appropriately. Under these circumstances, it is important for pilots to not only be aware of aircraft and operator limitations, but also their own personal limitations.

Preliminary report released December 2010

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 approximately 0710 on 23 October 2010, 15 wagons on freight train 3PW4 derailed near Wodonga, Victoria. There were no injuries but serious damage to rolling stock and track infrastructure was sustained during the derailment.

On 13 October 2010, a Boeing 717-200 (717), registered VH-NXD, was being operated by Cobham Aviation Services Australia, on a scheduled passenger flight from Perth to Kalgoorlie, Western Australia. On board were 97 passengers, three cabin crew and two flight crew.

During the approach to land on runway 29 at Kalgoorlie Airport, the stick shaker activated. The copilot, who was the pilot flying, reduced the aircraft's pitch angle and continued the turn onto final. About a minute later, the approach was no longer stabilised, and the flight crew conducted a go-around. On the second approach to land and after turning onto final, the copilot noted that the aircraft was below the required profile. As the copilot increased the aircraft's pitch attitude, the stick shaker activated for about 2 seconds. Following recovery actions, a go-around was conducted. The third approach was conducted by the pilot in command at an airspeed that was about 15 kts higher than the previous approaches.

The investigation found that the stick shaker activations were primarily a result of an incorrect approach speed. The approach speed generated by the flight management system (FMS) was based on a landing weight that was 9,415 kg less than the aircraft's actual weight. Prior to departure, the flight crew had inadvertently entered the aircraft's operating weight in lieu of the aircraft's zero fuel weight (ZFW) into the FMS. The data entry error also influenced the aircraft's take-off weight (TOW) in the FMS. The error went unnoticed and did not manifest as an operational problem until the approach into Kalgoorlie.

The investigation identified several organisational issues that had the potential to adversely affect the safety of future operations. Those issues related to the format of the aircraft load sheet, the verification check by the flight crew of the TOW against the load sheet and the lack of an independent validation check of the FMS-generated landing weight. In response, the operator has made a number of enhancements to the format of the 717 load sheet, the FMS weight data entry and verification procedures, the weight validation checks and the 717-simulator training in respect of recovery from stick shaker activation.

The application of correct operating data is a foundational and critical element of flight safety. In January 2011, the ATSB released a research report titled Take-off performance calculation and entry errors: A global perspective.

At about 1030 Eastern Standard Time on 18 October 2010, a Cessna 172S aircraft, registered VH-VSK, was operating at low level near Durham Downs Homestead, Queensland. A pilot and one passenger were on board.

The pilot was assisting a ground party locate two horses. The aircraft was seen manoeuvring at low level before radio and visual contact was lost. A search later found that the aircraft had impacted terrain near a dry creek bed. Both occupants received fatal injuries, and the aircraft was seriously damaged.

The aircraft's impact attitude was consistent with a loss of control following aerodynamic stall. The pilot was reported to have told another pilot a few days before the occurrence that the aircraft's stall warning system was inoperative. However, the status of the stall warning system at the time of the occurrence could not be confirmed. The investigation identified some other issues which also could have influenced the safety of the flight.

The aircraft operator introduced a number of changes to its policies and procedures following the occurrence.

Safety summary

What happened

At about 1450 on 8 October 2010, the partially loaded Liberian registered bulk carrier Grand Rodosi collided with the Australian fishing vessel Apollo S in Port Lincoln, South Australia. As a result of the collision, Apollo S, which was unmanned, was crushed against the wharf and sank shortly afterwards. Grand Rodosi sustained several relatively small holes in its bow shell plating.

What the ATSB found

The ATSB investigation found that, despite the pilot ordering astern movements, the ship's main engine did not run astern in the 5 minutes leading up to the collision. The chief engineer, who was operating the main engine start/fuel lever in the engine room control room, did not allow sufficient time for starting air to stop the ahead running engine. Consequently, when fuel was introduced into the engine, it continued to run ahead, despite the astern telegraph orders.

The investigation also found that the chief engineer's mistake was not identified by anyone on the ship's bridge or in the engine room control room until after the collision; that the master/pilot information exchange was less than optimal; and that bridge resource management principles could have been better applied during the passage to the berth.

What has been done as a result

Newlead Bulkers, the ship's managers, have amended their on board procedures to ensure crew monitor the direction of main engine turning after each engine order. They have also increased awareness through their fleet about this type of incident occurring.

Flinders Ports, the provider of pilotage services in Port Lincoln, have revised their risk assessment for the manoeuvre being undertaken during Grand Rodosi's berthing to include new preventative, as well as restorative, measures to be followed. Flinders Ports has also revised the port's pilotage passage plan to include indicative courses to be followed, both while transiting the channel and outside of it, and speed zones. This will enable the crews of visiting ship to be better informed about the pilotage passage their ship is about to undertake.

Safety message

It is of paramount importance that pilots and ships' crews maintain awareness of main engine movements and check engine tachometers following every movement to ensure that the engine is operating in the desired direction. This is particularly important when main engines are being operated in manual control.

In addition, pilots and the bridge teams should ensure that all the necessary information is exchanged at the beginning of a pilotage, including courses to be followed and speeds at critical positions during the passage to or from the berth/anchorage, so that all members involved in the pilotage have a shared mental model and therefore, a good understand of the pilotage before it begins.

On 15 October 2010, the pilot of a Gippsland Aeronautics GA-8 Airvan, registered VH-DQP, was conducting a charter flight from Lady Barron, Flinders Island to Bridport, Tasmania with six passengers on board. The aircraft departed Lady Barron Aerodrome at about 1700 Australian Eastern Daylight-saving Time and entered instrument meteorological conditions (IMC) several minutes afterwards while climbing to the intended cruising altitude of about 1,500 ft. The pilot did not hold a command instrument rating, and the aircraft was not equipped for flight in IMC. He attempted to turn the aircraft to return to Lady Barron Aerodrome but became lost, steering instead towards high ground in the Strzelecki National Park in the south-east of Flinders Island.

At about 1715, the aircraft exited cloud in the Strzelecki National Park, very close to the ground. The pilot turned to the left, entering a small valley in which he could neither turn the aircraft nor out climb the terrain. He elected to slow the aircraft to its stalling speed for a forced landing and, moments later, it impacted the treetops and then the ground. The first passenger to exit the aircraft used the aircraft fire extinguisher to put out a small fire that had begun beneath the engine. The other passengers and the pilot then exited the aircraft safely. One passenger was slightly injured during the impact; the pilot and other passengers were uninjured.

During the night, all of the occupants of the aircraft were rescued by helicopter and taken to the hospital in Whitemark, Flinders Island.

Executive summary

On 4 October 2010, 604 packs of timber veneer were lost overboard from the deck of the Panama registered multipurpose cargo ship Mimasaka. At the time, the ship was in rough seas, about 27 miles southeast of Yamba, New South Wales.

The ATSB investigation found that the cargo stowage and securing instructions that had been emailed to the ship did not provide the crew with sufficient guidance about how the deck cargo was to be stowed or secured. Consequently, the deck cargo was not appropriately secured and it moved in the heavy weather. This resulted in the failure of the lashing system and the subsequent loss of the cargo.

The investigation also found that the ship's cargo securing manual did not contain any instructions on the stowage and securing of timber veneer cargoes. Furthermore, the operations manual provided by NYK-Hinode Line for the stowage and securing of timber veneer did not contain any information or guidance for the stowage and securing of the cargo on the ship's hatch covers.

The ATSB identified five safety issues during the investigation. They include the lack of guidance provided to the crew by NYK-Hinode Line, that the shipper of the veneer did not follow the recommendations for packaging contained in Appendix A of the International Maritime Organization's Code of Safe Practice for Ships Carrying Timber Deck Cargo and that no third party had inspected the packaging to see whether the shipper had followed those recommendations.

The ATSB acknowledges the safety action taken by the organisations responsible for the safety issues and is satisfied that the safety action adequately addresses those safety issues.

Executive summary

At about 1944 on 6 October 2010, the offshore supply vessel Far Swan collided with the barge Miclyn 131 in the port of Dampier, Western Australia. At the time, Miclyn 131 was being towed by the Western Australia registered vessel Global Supplier. Both Far Swan and Miclyn 131 sustained minor damage as a result of the collision but there were no injuries or pollution.

The ATSB investigation found that Global Supplier's skipper was not keeping a proper lookout at the time of collision and that Miclyn 131's navigation lights were not appropriately mounted.

The investigation also identified three safety issues: that Global Supplier was not exhibiting the correct navigational lights for a vessel engaged in towing operations; Dampier Port Authority's pilotage directions were unclear and ambiguous with respect to the requirements for towing vessels or on the use of pilotage exemptions by crew other than the master; and that Global Supplier was not fitted with radar or an AIS unit which would be required under the provisions of the current National Standard for Commercial Vessels.

The ATSB is satisfied with the safety actions taken to address two of these issues but has issued a safety advisory notice about the lack of a requirement for the carriage of radar and AIS on small commercial vessels surveyed under the Uniform Shipping Laws code.

On 12 October 2010, a Piper Aircraft Corporation PA-31-350 aircraft, registered VH-TAS (TAS), departed Griffith, New South Wales on scheduled freight service to Narrandera.

When about 37 km from Narrandera, the pilot broadcast an inbound call on the common traffic advisory frequency (CTAF). Shortly after, the pilot heard a broadcast from the pilot of a Cessna Aircraft Company 441 aircraft, registered VH-XBC (XBC), advising that he was taxiing for runway 32. The pilot of TAS attempted to contact the pilot of XBC a number of times, but received no reply.

When established on final for runway 14, the pilot observed the landing lights of XBC taking off on the reciprocal runway, runway 32.  The pilot of TAS initiated a right turn. The pilot of XBC observed TAS turning and elected to continue straight ahead. The aircraft passed at about 500 ft above ground level (AGL), with an estimated horizontal distance between 1-2 km.

Subsequent communications between the two pilots identified that the pilot of XBC did not hear any broadcasts made by the pilot of TAS until after the incident occurred.

A recent research report published by the ATSB identified that the most prevalent type of accident or incident occurring at non-towered aerodromes involved conflicts between aircraft, or between aircraft and ground vehicles. Despite this, operations at these aerodromes are generally safe. However, pilots should ensure that they maintain awareness of their surroundings and of other aircraft, fly in compliance with procedures, and be observant, courteous and cooperative at all times.