On 5 August 2009, during on a scheduled flight from Melbourne, Victoria (Vic) to Mackay, Queensland (Qld), the flight crew of an Airbus A320-232 aircraft, registered VH-VND, were advised of an electrical burning smell in the mid cabin area. Within 5 minutes of that advice, multiple left and right engine warnings were observed on the electronic centralised aircraft monitoring (ECAM) display. The flight was diverted to Canberra, Australian Capital Territory (ACT) where an uneventful landing was conducted.

Subsequent examination found the electrical burning smell had originated from a fluorescent light ballast resistor in the cabin. The ECAM warnings were attributed to an internal fault in the number 2 display management computer (DMC).

Following similar incidents, the DMC manufacturer introduced a cyclic software check of parameters used in the receiving function, with an auto reset of the DMC if corrupted parameters were identified.

The aircraft manufacturer reviewed its operational procedures and provided operators with additional procedures for flight crew to transfer from a faulty DMC to an alternate DMC during flight or reset a faulty DMC on the ground.

Executive summary

At approximately 0644 Eastern Standard Time on 2 June 2006 the crew of Interail freight service 5MB7 reported that their train had derailed while traversing the No. 3 points located at the Melbourne end of the Benalla crossing loop. Both locomotives derailed along with 19 wagons. Two track machines stabled within the cripple road adjacent the crossing loop were heavily damaged along with the nearby Victorian Railway Institute Hall which sustained severe structural damage.

There were no serious injuries as a result of the collision.

The investigation found that the driver of train 5MB7 had probably failed to correctly interpret and respond to signal ES6377. As a result, he was unable to slow the train to a safe speed when traversing No. 3 points located at Melbourne end of the Benalla crossing loop.

In the interest of enhancing future rail safety the ATSB has made seven recommendations which include a review of crew resource management strategies, an examination of mentoring responsibilities and reviewing processes for the re-certification of drivers.

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Rail Recommendations [ RR20070015 ] [ RR20070016 ] [ RR20070017 ] [ RR20070018 ] [ RR20070019 ] [ RR20070020 ] [ RR20070021 ]

Abstract

At about 1535 on Saturday 1 August 2009, the lead locomotive of Pacific National (PN) freight train 5PM5 collided with a utility motor vehicle at the Bumbunga level crossing in South Australia (SA).

The utility vehicle was seriously damaged as a result of the collision and the male driver and a female passenger were fatally injured.

The train driver was uninjured. The lead locomotive of the train incurred minor damage, mainly to the headstock/pilot at the front of locomotive. The track and level crossing infrastructure incurred moderate damage that consisted of damaged rail fasteners and gouging of the road surface at the level crossing.

Executive summary

At approximately 1322 on 5 June 2006, a passenger car (a 1986 Holden Commodore sedan) drove into the path of XPT passenger train (ST24) at the Thurgoona Road level crossing, on the northern edge of Albury, New South Wales.

The driver of the passenger car was fatally injured during the collision.

The investigation concluded that the effect of non-prescription drugs on driver performance and driver distraction due to mobile phone operation were safety factors which contributed to the collision.

Executive summary

At about 1448 on Wednesday 5 March 2008, a double road-train loaded with bulk cement drove into the path of a train that was conveying four empty fuel tankers at the Stirling Street level crossing, Birkenhead, SA. The impact speed of both the train and road-train was low (about 15 km/h) but nevertheless sufficient to roll the prime mover and the first semitrailer onto their sides and to derail the lead bogie of the train's locomotive. The road-train driver was slightly injured; the two train drivers were shaken but otherwise unhurt.

Road traffic at the Stirling Street level crossing was controlled by 'Stop' sign assemblies. At the time of the collision, the level crossing was in the process of being converted from passive (Stop sign) to active control (flashing lights and boom barriers) as part of a major road upgrade called the 'Port River Expressway Project'. The investigation found that the Stop sign assembly was moved from its original position sometime during the upgrade and a 'Stop' line was not visible on the road surface. In the absence of a Stop line, visibility along the rail line was, at best, intermittent.

The investigation concluded that it is likely the road-train did not stop at the Stop sign assembly and travelled over the Stirling Street level crossing at a relatively constant speed of about 15 km/h. The investigation also found that the road-train involved in the collision was not authorised to operate on Stirling Street as no Heavy Vehicle Permit (HVP) for this vehicle had been issued by the Department for Transport, Energy and Infrastructure.

Safety issues identified by the investigation relate to compliance of the level crossing with relevant standards, notification to the rail infrastructure manager of a non-compliance identified at audit and the issuing of HVP's for road-train routes that involve level crossings. The ATSB has acknowledged proactive safety action taken by relevant parties in response to those identified safety issues. In addition, the ATSB has issued four safety recommendations.

Safety issues

On 25 July 2009, a Boeing 737-7Q8 aircraft, registered VH-VBA, was taxiing toward the runway for departure at Melbourne aerodrome, Victoria, when the crew reported hearing a loud thud from the airframe. The crew of a passing company aircraft advised the crew of VH-VBA that they had lost a nose wheel tyre. It was subsequently discovered that the right wheel had detached from the nose landing gear (NLG) as a result of a fracture of the axle.

An Australian Transport Safety Bureau investigation of the NLG failure determined that the nose wheel had separated as a result of the initiation and propagation of a fatigue crack through the right, inboard bearing journal. The fatigue crack had originated under the influence of residual stresses in the steel surface associated with grinding damage during manufacture, and its initiation was probably hydrogen-assisted from plating processes applied to the journal bearing surfaces.

As a result of the occurrence, the aircraft operator conducted an immediate, fleet-wide inspection of axles with similar service history. To reduce the likelihood of future possible axle failures, the aircraft manufacturer conducted an audit of the landing gear supplier's processes and production records, in an attempt to establish the extent of the grinding problem. The aircraft manufacturer also released a communication to 737 operators and maintenance providers, detailing enhanced inspection recommendations for the identification of grinding damage.

On 9 July 2009, at about 2108 Eastern Standard Time a British Aerospace BAe Jetstream 32 aircraft, registered VH-OTD, was being operated on a scheduled passenger service from Sydney to Williamtown, New South Wales (NSW), with two crew and six passengers.

During climb to 9,000 ft, and about 19 km northeast of Sydney, the flight crew noticed a strong electrical burning smell in the cabin. The flight crew requested and received clearance from air traffic control for an immediate return to Sydney. Faced with a high workload, the crew chose not to don their emergency oxygen masks during the return flight to Sydney.

Following an uneventful landing, the crew noticed a light haze of smoke below the roof of the cabin. After the passengers disembarked, engineering staff located the source of smoke as the weather radar indicator.

Examination of the weather radar indicator found that burning of a control circuit board had occurred, damaging the printed circuit board substrate. The damage was not the result of an aircraft system fault.

Research published by the ATSB has shown that the second most common cause of in-flight medical and incapacitation events was exposure to toxic smoke and fumes. Use of supplemental breathing equipment is an important defense against pilot incapacitation.

On 14 July 2009, at about 0948 Central Standard Time, the flight crew of a Boeing 717-200 aircraft, registered VH-NXN, were conducting a
visual approach to runway 13 at Ayers Rock, Northern Territory. While carrying out a practise circling approach, the pilot in command observed what he believed to be abnormal engine response.

While the flight crew addressed the apparent engine problem, the aircraft's airspeed reduced below the normal manoeuvring speed on two occasions. However, the aircraft landed without further incident and a subsequent analysis of recorded data indicated that safe control of the aircraft was maintained throughout.

In response to this incident, the operator issued a Notice to Pilots regarding autothrottle mode awareness and made a number of changes to the Boeing 717 operations manuals.

Those changes described a number of restrictions on the automation modes used during critical stages of flight that the operator believed were appropriate to prevent automation 'surprises'.

he Australian Transport Safety Bureau (ATSB) has completed its technical analysis investigation into the failure of two reciprocating piston engine crankcase through-bolts, on behalf of the Australian Civil Aviation Safety Authority (CASA). CASA was the principal investigating agency in this instance. CASA requested assistance from the ATSB in the examination and analysis of the metallurgical aspects of the bolt failure. To facilitate the examination, the ATSB commenced an investigation under the Transport Safety Investigation Act (2003).

The ATSB's Technical Analysis Report has been sent to CASA to assist its ongoing investigation.

Contact details for CASA are: www.casa.gov.au

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