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.

On 21 September 2010, a Qantas Airways operated, Airbus A330-200 aircraft, registered VH-EBM, was being operated on a scheduled passenger service from Perth, Western Australia to Melbourne, Victoria.

During the flight, the weather conditions at Melbourne Airport deteriorated and the flight crew were required to conduct a Category III instrument landing system (ILS) approach and autoland. The weather continued to deteriorate. Low Visibility Procedures were not active when the aircraft landed at 2354, and the critical areas around the ILS ground based equipment were not protected from potential signal interference. After landing, the crew advised air traffic control that that the runway visual range at the touchdown area was down to between 300‑400 m.

Low Visibility Procedures represented the activation of additional procedures at the aerodrome for the restriction of access to the aerodrome movement area by vehicles and pedestrians, and the management of ground traffic, including taxiing aircraft, when the Runway Visual Range was reported as 800 m or less.

In November 2010, Airservices Australia issued a Safety Bulletin to pilots to clarify when the ILS would be protected from signal interference.

This incident highlights for Air Traffic Controllers and aircraft operators that the time required by the airfield operator to secure the critical and sensitive areas of the Instrument Landing System for Low Visibility Procedures can be lengthy. In addition, the incident demonstrates the importance of air traffic control providing timely and current information to flight crew, including the update of the Automated Terminal Information Service, regarding deteriorating weather conditions.

Abstract

At about 0415 on 8 October 2010, freight train 5MP5 travelling from Melbourne to Perth reported having derailed on the Defined Interstate Rail Network (DIRN) between Wirrega and Keith in South Australia.

No one was injured and there was only minor damage to rolling stock during the derailment, however approximately 400 m of track required repairs before services could resume and 2900 concrete sleepers were subsequently replaced to restore track integrity.

It was established that the derailment was the result of a screwed journal on the 12th wagon (RQJW 22034D) in the consist behind the locomotives.

At about 0822 Eastern Daylight-saving Time on 10 October 2010, the pilot of a Eurocopter AS350B Squirrel helicopter, registered VH-ROU, inadvertently entered cloud while operating a visual flight rules charter flight from Parramatta heliport to Bathurst, New South Wales (NSW) with five passengers on board. The pilot became spatially disoriented and exited the base of the cloud just prior to colliding with terrain next to the Oaks Fire Trail, which was about 2 km south of Woodford, in the Blue Mountains region of NSW. Two of the passengers sustained minor injuries and were taken to hospital. The helicopter was seriously damaged.

The investigation found that, in the hours prior to, and during the flight, several operational and tactical decisions were made that did not adequately address the risk of visual flight into instrument meteorological conditions. In addition, a minor safety issue was identified in respect of the lack of a requirement for a charter‑specific risk assessment for the flight. The result was that the risks associated with the charter were not adequately addressed. In response, the operator has advised that the operations manual will be amended to require risk assessments in support of all operational flights.

On 5 October 2010, at 2115 Eastern Standard Time, a Boeing Company 737-8FE, registered VH-VUR, had completed push back from parking bay 47 at Brisbane aerodrome, Queensland. The handling engineer disconnected the power push unit (PPU) from the aircraft and the pilot in command (PIC) received clearance from air Traffic Control (ATC) to taxi via taxiway C6.

As the aircraft moved away from the disconnect point on the apron, the PIC steered the aircraft to the left instead of right. This required the PIC to make a tight 270⁰ turn to continue along the apron to taxiway C6. During the 270⁰ turn, the dispatch engineer had to quickly manoeuvre the PPU to avoid a collision with the aircraft and, at the same time, avoid the hot exhaust emissions from the aircraft turbine engines.

This occurrence reinforces the importance of the flight crew maintaining situational awareness when manoeuvring aircraft.

As a result of this occurrence, the aircraft operator notified their flight crew and issued a flight crew operational notice.