Executive summary

At about 1411 on Wednesday 9 September 2009, scheduled XPT passenger train ST24, en route from Melbourne to Sydney, passed signal JE02 at Junee by about 33 m while that signal was displaying a Stop (red) indication. No injuries or damage resulted from the occurrence.

The driver of ST24 said that signal JE26, the signal before JE02, was displaying a Medium Turnout indication and this meant that signal JE02 would be showing a Proceed aspect. Several other rail employees also said that signal JE26 was displaying a Medium Turnout indication. However, the investigation concluded that it was almost certain that signal JE26 was displaying a Caution Turnout indication rather than a Medium Turnout indication, which would have resulted in signal JE02 displaying a Stop indication. The investigation concluded that the driver's perception of signal JE26 was influenced by expectation, distraction and possibly fatigue, and that the employee witnesses' perception of the signal was influenced by expectation, 'confirmation bias' and 'group think'.

The report identifies three safety issues in relation to prioritisation of operational tasks, signal lamp voltage and signalling design standards.

Preliminary report released 20 November 2009

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.

Abstract

At 0151½ on 9 September 2009, in a position about 15 miles east of Point Lookout on North Stradbroke Island, Queensland, the Australian registered, single-handed yacht Ella's Pink Lady collided with the Hong Kong registered bulk carrier Silver Yang.

At the time of the collision, Silver Yang was en-route to China and travelling at a speed of about 9 knots on a northerly heading. Ella's Pink Lady was under sail on a voyage from Mooloolaba, Queensland, to Sydney, New South Wales. The yacht was making good a course of 144°(T) and a speed of about 7 knots.

Ella's Pink Lady was dismasted as a result of the collision, but the skipper was able to cut the headsail free, retrieve the damaged rigging on board and motor the damaged yacht to Southport, Queensland.

On 20 September 2009, at about 1630 Western Standard Time, a Boeing 737-400 (737) aircraft, had been pushed back from the domestic terminal onto the taxiway at Perth Airport, Western Australia (WA), when a technical fault was experienced. The aircraft remained in position to allow the flight crew to examine the fault. At the same time, a Boeing 717- 200 (717) aircraft, located in an adjacent bay, requested a pushback clearance from the surface movement controller (SMC). The SMC advised the 717 flight crew to contact their ground crew to discuss suitable pushback options. The 717 was pushed back with the aircraft kept as close to the terminal as possible. A clearance marshaller was located next to the left wing of the 717.

The flight crew of the 737 and the ground engineer for the 717 estimated that the wing of the 717 and the nose of the 737 were 11 m apart. However, the ground engineer for the 737 reported that the distance between the two aircraft was within 1 m and that as a result, he and another ground engineer with him may have been placed within the inlet and exhaust hazard area of the 717.

It was not possible to reconcile the differing accounts of aircraft proximity. However, the incident highlights the potential dangers associated with ground operations around jet aircraft and the need for particular care and attention when dealing with dynamic traffic situations.

On 3 September 2009 at about 1859 Eastern Standard Time, a Boeing 737-838 aircraft was en route from Sydney, New South Wales to Adelaide, South Australia and a Boeing 777-31H aircraft was en route from Melbourne, Victoria to Singapore. The aircraft were on crossing tracks and both were cruising at flight level 300. The air traffic control separation standard was infringed and there was a breakdown of separation.

The air traffic controller responsible for separation of the aircraft had recently completed the air navigation service provider's approved training, but had not recognised the potential conflict between the two aircraft.

As a result of this incident, Airservices Australia has amended the compromised separation recovery component of an air traffic controller's training, and introduced a compromised separation recovery element into its final controller field training.

At about 1100 Eastern Standard Time on 23 June 2009, a Bell Helicopter Company 206B JetRanger III helicopter, registered VH-CAP commenced agricultural spraying operations at a property located 24 km north-north-east of Albury Aerodrome, New South Wales. At 1223 the pilot repositioned to commence an impromptu spray run that resulted in the helicopter flight path crossing a powerline that was known to the pilot.

The pilot reported that during the impromptu spray run, he was preoccupied with a request from the property owner to modify the planned spray sequence and forgot about the wire until he sighted it a short distance ahead. In response, the pilot initiated a climb to avoid the wire. He heard the helicopter contact the wire and felt the wire arrest the forward movement.

Although the helicopter was fitted with wire-strike protection system (WSPS) equipment, the wirestrike was outside the strike angle and cable span design parameters of the WSPS. The investigation was unable to determine whether the WSPS might have operated as intended, had the wire continued its initial movement towards the cutter blades before itself breaking.

The pilot's last recollection was seeing the ground rapidly approaching. He regained consciousness an unknown period of time later, still securely restrained in the wreckage. He managed to extricate himself and notify his ground crew. The pilot sustained minor injuries.

The investigation found that the inherent difficulty in visually detecting the wire, combined with the operating groundspeed required for chemical application meant that the pilot did not have sufficient time to avoid the wirestrike.

Although no safety issues were identified as a result of this investigation, the protection afforded by the pilot's helmet and the secure restraint offered by the pilot's four-point harness, probably prevented serious, if not fatal injury. Operators and crew would benefit from the consideration of the use of flying helmets, and when feasible, installation of four-point harnesses in their aircraft, particularly during inherently higher risk operations.

On 31 August 2009 at 1344 Eastern Standard Time, the pilot of a Beech Aircraft Corporation B200T, registered VH-LAB, suffered a seizure and was rendered unconscious, while the aircraft was descending from flight level (FL) 2002 to FL150 inbound to the Bindook VOR. The aircraft was being flown using the aircraft's autopilot coupled to the Global Positioning System (GPS). The aircraft crewman attended to the pilot and notified Air Traffic Control (ATC) of the occurrence.

In the ensuing 20 minutes, the pilot gradually regained consciousness and at 1418 initiated and successfully completed an approach and landing at Bankstown airport.

It was later determined that the pilot had a previously undiscovered medical condition that was the likely cause of the in-flight seizure.

On 25 August 2009, a Piper Cherokee PA28-161 aircraft, registered VH-FKU, was approaching Bankstown Aerodrome, New South Wales (NSW) from reporting point 2RN in the south-west to join on a crosswind leg for runway 29 right (29R). At the same time, a Piper Chieftain PA31-350 aircraft, registered VH-HJH, was approaching Bankstown Aerodrome from Cessnock to join on a downwind leg for runway 29R. Both aircraft were being operated under the visual flight rules.

The pilot of the Cherokee was given traffic information by air traffic control and instructed to widen out to the left and told to expect to follow the Chieftain that was tracking to join on a downwind leg for runway 29R. The pilot of the Cherokee acknowledged the instruction but subsequently turned downwind in front of and inside the flightpath of the Chieftain. Traffic information was passed to the pilots of both aircraft, and the pilot of the Chieftain made a steep descending turn to avoid a collision.

On 2 July 2009, the pilot of a Robinson Helicopter Company R22 Beta II, registered VH-OML, was conducting solo circuit training from the Gold Coast Aerodrome, Queensland. Weather conditions in the area at the time were fine, with light and variable winds.

At about 1015 Eastern Standard Time, the helicopter impacted terrain near the southern aerodrome boundary. The pilot was fatally injured and the helicopter seriously damaged.

There was no evidence of a pre-existing mechanical problem with the helicopter. The pilot had extensive previous experience in aeroplanes and the flight was his sixth solo helicopter flight towards his Private Pilot (Helicopter) Licence. The investigation found that the accident may have been a function of the pilot's control inputs.

As a result of this investigation, the helicopter operator has made a number of changes to their induction process, including the annotation in company records of instructors' ratings and their respective validity periods. In addition, the Civil Aviation Safety Authority has advised that it will review the requirements for initial pilot training and endorsement and recurrent training on Robinson R22 helicopters. Included will be a review of the Helicopter Flight Instructor's Manual to ensure that the required competencies are being covered by flight instructors and trained to students.

The Australian Transport Safety Bureau has issued a Safety Advisory Notice suggesting that operators consider action to ensure the validity of pilots' qualifications and ratings, and that competency standards are met.

On 24 June 2009, the pilot of a Robinson Helicopter R22 Beta II, registered VH-HXO, departed Mareeba, Queensland on a private flight to Uaroo, Western Australia (WA) as the helicopter had been contracted to an operator for aerial mustering tasks. After an overnight stay at Alice Springs, Northern Territory, the pilot departed for Uaroo on 25 June 2009. The last known stop for the pilot was the night of 25 June 2009, at Newman, WA. After refuelling, the pilot departed sometime during that night. The following morning, after the expected arrival time of the helicopter, and after several attempts to contact the pilot, Australian Search and Rescue commenced a search for the missing helicopter. The wreckage was located about 120 km west of Paraburdoo, WA. The pilot was fatally injured as a result of the accident.

The investigation found no evidence of a pre-existing mechanical problem with the helicopter. After consideration of the available evidence, the investigation concluded that the accident may have been a function of the pilot's control inputs, possibly resulting from pilot fatigue, carburettor icing, night flight, or a combination of these factors.

The investigation did not identify any organisational or systemic issues that might adversely affect the future safety of aviation operations. However, the accident does provide a timely reminder of the need for pilots conducting private operations to consider the impact of fatigue; particularly, during a long flight over a number of days, as was the case in this occurrence.

At Indonesia's request, the Australian Transport Safety Bureau (ATSB) appointed an accredited representative in accordance with Clause 5.23 of Annex 13 to the Convention on International Civil Aviation, to participate in the NTSC's investigation into the fatal accident in the Makassar Strait, Indonesia, involving a Boeing 737 operated by AdamAir.

The aircraft disappeared off radar and crashed into the ocean. The aircraft was destroyed and the two pilots, four flight attendants and 96 passengers on board were fatally injured.

Australia's accredited representative to the investigation worked closely with the NTSC throughout the investigation.

To protect the information supplied by the NTSC to the ATSB and investigative workload undertaken to assist the NTSC, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

On 25 March 2008, the NTSC published its final report into the accident on its website.

National Transportation Safety Committee
Ministry Of Transportation Republic Of Indonesia
Transportation Building 3^rd Floor
Jalan Medan Merdeka Timur No. 5
Jakarta Pusat 10110
Indonesia

Phone  :  +62 21 384 7601
Email    :  knkt@dephub.go.id

Website: http://knkt.dephub.go.id/knkt/ntsc_home/ntsc.htm

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Released in accordance with section 25 of the Transport Safety Investigation Act 2003.