At 1118 Eastern  on 1 January 2009 a laden waste disposal truck drove into the path of The Sunlander passenger train at the Aerodrome Road level crossing, Mundoo (near Innisfail) North Queensland. The two lead locomotives and following six carriages derailed in the collision. As a result of the collision the truck driver was fatally injured. Both of the train drivers, nine passengers and four QR on-board staff members sustained minor to moderate injuries. Of those injured, six passengers and one QR employee were taken to hospital for observation.

The investigation was conducted by the Department of Transport and Main Roads in accordance with provisions of Queensland's Transport Infrastructure Act 1994 (the Act), independently chaired by a senior rail safety investigator of the Australian Transport Safety Bureau.

Rail safety in Queensland is regulated by the Department of Transport and Main Roads. All railway managers and/or railway operators within Queensland are required to be accredited in accordance with the Act. The Department of Transport and Main Roads' role in rail safety also includes the investigation of railway incidents.

The final report is available via Queensland Transport.

• Queensland Transport website

Preliminary report released 18 September 2009

This accident is being investigated by the Papua New Guinea Accident Investigation Commission (AIC) in accordance with its obligations under Annex 13 to the Convention on International Civil Aviation. The AIC requested the Australian Transport Safety Bureau (ATSB) to assist their investigation by providing investigator support, information and technical advice and facilities support.

In accordance with paragraph 5.23 of Annex 13, the ATSB appointed an Accredited Representative and a number of advisors to the Accredited Representative (ATSB investigators) to assist the AIC during the on-site phase, in the technical examination of a number of recovered aircraft items and components, and as requested by the AIC during the remainder of the investigation. In addition, the ATSB supported the AIC in the development of its Preliminary Factual Report. An abstract drawn from that report follows:

At about 1055 local time on 11 August 2009, the pilot of a De Havilland DH-6 Twin Otter (Twin Otter) aircraft, registered P2-MCB, reported departure from Jacksons Aerodrome, Port Moresby on a charter flight to Kokoda, Papua New Guinea. On board the aircraft were two crew and 11 passengers. The weather in the area was forecast to include isolated showers and thunderstorms, with areas of rain. In addition, significant layers of cloud were forecast from 800 ft above ground level to 18,000 ft, with isolated embedded Cumulo Nimbus cloud within those layers.

The pilot's estimated time of arrival at Kokoda was 1120.

The flight service operator for the area made a number of attempts to contact the pilot by radio in order to advise of other traffic but without success. At 1135, another of the company's aircraft that was in the area advised flight service that the Twin Otter had not arrived at Kokoda.

At about 0810 on 12 August 2009, a search aircraft detected an emergency locator transmitter signal and, shortly after, visually identified aircraft wreckage on the eastern side of the Kokoda Gap, about 6 NM (11 km) south-east of Kokoda Aerodrome.

The aircraft had impacted steep, heavily-timbered terrain in a near-level attitude and was seriously damaged. The aircraft occupants were fatally injured.

The investigation is continuing and will include:

• examination of the items that were recovered from the accident site
• review of the relevant operational documentation
• review of the aircraft's weight and balance
• review of the forecast and actual weather conditions at the time of the occurrence
• conduct of a number of interviews with relevant persons and organizations
• review of the relevant risk controls and potential organisational influences that may have contributed to the development of the occurrence.

A full copy of the Papua New Guinea Accident Investigation Commission report titled Aircraft accident interim report involving DH-6. P2-MCB near Kokoda on the 11 August 2009 (File ref AS.09.1005) is available from the link on the right.

Any media enquiries in respect of the AIC report should be directed to:

Mr David Inau
CEO, Accident Investigation Commission
Telephone: +675 311 2406
Email: ceoaicpng@hotmail.com

Address:  
Accident Investigation Commission    
PO Box 1790, Boroko
National Capital District
Port Moresby, Papua New Guinea

Interim Factual report released 8 December 2005

At 1200 Eastern Standard Time (EST) on 26 October 2005, the outboard bead heel of the number-1 wheel tyre on the left main landing gear (MLG) of an Airbus A340-642 aircraft, registered HS-TNA, separated from the outboard rim of the wheel assembly during a landing on runway 16 at Melbourne International Airport, Victoria. The landing was conducted during strong crosswind conditions. The aircraft was on a scheduled passenger service from Bangkok, Thailand, with a crew of 19 and 247 passengers. The copilot was the handling pilot for the flight. There were no reported injuries to any of the aircraft occupants.

The number 1 wheel tyre deflated immediately after the bead heel separated from the wheel rim. The tyre then partially disintegrated during the remainder of the landing roll, and the tyre tread detached from the tyre casing (see Appendix 1).

Contact with the runway surface scored and scratched the outboard rim of the number 1 wheel assembly after the tyre deflated (see Figure 2).

Fragments of rubber dislodged from the disintegrating tyre resulted in some minor skin damage to the underside of the left wing and the left underside of the fuselage near the left MLG. Rubber fragments also broke off a small portion of the left MLG fairing door and dislodged a small inspection panel on the inboard side of the number 2 engine pylon. The disintegrating tyre also damaged a hydraulic brake line on the left MLG. The heat from the rear left MLG inboard wheel-brake assembly ignited hydraulic fluid, which leaked from the damaged brake line. The airport rescue and fire fighting service rapidly extinguished the fire.

The number 1 wheel rim damaged the surface of runway 16 after the tyre separated from the rim (see Figure 3). Appendix 2 depicts the extent of the markings and gouging to the surface of runway 16/34 as a result of the occurrence.

The Bureau of Meteorology weather radar data indicated that a cold front passed through Melbourne International Airport at about 1130. The 0200 Coordinated Universal Time (1200 EST) aerodrome routine meteorological report for Melbourne Airport included information that the wind direction and speed were 260 degrees true (T) at 23 kts, gusting to 29 kts. Melbourne Airport automatic terminal information service 'Yankee', issued at 1130, included information that the wind direction and speed were 230 to 280 degrees magnetic (M) at 18 to 30 kts, with a maximum crosswind of 14 kts.

The preliminary solid state flight data recorder (SSFDR) parameters examined by the Australian Transport Safety Bureau (ATSB) included:

• wind speed (kts) and direction (degrees T)
• radar altimeter (RALT, providing absolute altitude in feet above ground level)
• aircraft heading (degrees M)
• aircraft roll (degrees)
• aircraft landing gear AIR/GROUND status
• vertical and lateral accelerometer 'g' loadings.

The data revealed that the wind direction during the landing approach from 850 ft RALT was about 250 degrees T, allowing for some minor variations. Wind speed from between 850 ft and 400 ft RALT was about 22 kts, with a maximum 27 kts occurring at 500 ft RALT. From 400 ft RALT, the wind speed reduced to about 18 kts. About 6 seconds before touchdown, the wind speed began to increase and reached a peak of 40 kts about a 1⁄2 second before the right MLG parameter transitioned from AIR to GROUND.

The aircraft's heading remained relatively constant between 166 and 168 degrees M from 850 ft RALT, then increased to 175 degrees M, coincident with the wind gust encountered just before touchdown. The aircraft touched down with 15 degrees right yaw ('crab'), on a heading of 175 degrees M, and rolled in a 5-degree right wing low attitude.

The right MLG parameter was the first to transition from AIR to GROUND at touchdown, followed by the left MLG, then the centre MLG. The centre MLG parameter then transitioned back from GROUND to AIR, followed by the right MLG, indicating a 'bounced' landing. The right MLG parameter transitioned back to GROUND 1⁄2 second later. The left MLG parameter remained in the GROUND parameter after the initial touchdown.

Touchdown vertical 'g' loading was about 1.6 'g', and lateral 'g' loading was about 0.4 'g' to the left, indicating that the aircraft was in a right sideslip.

The investigation is continuing and will further examine recorded flight and cockpit voice data to better understand the circumstances leading up to the occurrence.

Recorded data covering environmental conditions are also being examined to assess any effect on the aircraft.

Appendix 1

Appendix 2

A fractured rigid fuel injector line from a Textron Lycoming IO540-C4B5 reciprocating piston engine was received by the Australian Transport Safety Bureau from the Civil Aviation Safety Authority (CASA), with a request to determine the mechanism of failure and the likely contributing factors. It was reported that the line had fractured during engine operation, spraying pressurised aviation gasoline into the engine compartment. The released gasoline did not catch fire.

The line had fractured in a single location, adjacent to the union at the injector (cylinder) end. Metallurgical examination determined that the fracture was the end result of high-cycle fatigue crack growth; cracking having initiated at one of a number of large corrosion pits on the lines external surface.

Analytical techniques identified the line as a UNS S30400 austenitic stainless steel; a material susceptible to pitting corrosion attack in the presence of chlorides. Chloride compounds were detected within the corrosion pits and were attributed to the salt-laden air associated with the coastal environment in which the engine/aircraft had been operating.

Safety action initiated as a result of the investigation findings included CASA revising airworthiness directives AD/LYC/90 and AD/CON/60; related to the maintenance of fuel injection supply lines on Textron Lycoming and Teledyne Continental aircraft engines respectively. Additionally, CASA published an information article in their periodical Flight Safety Australia, providing a summary of the event and investigation findings, together with advice and guidelines for maintenance personnel when installing and maintaining fuel injector lines.

The ATSB assisted the New Zealand Transport Accident Investigation Commission (TAIC) in their investigation into the loss of the vessel. TAIC is the lead agency in this investigation.

The inter-island ferry, the MV Princess Ashika, sank in Tongan waters 5 August 2009. There were many lives tragically lost. Pursuant to the Royal Commission Act (Cap 41) Laws of Tonga, a Royal Commission into the Sinking of the MV Princess Ashika was established.

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.

Download final report

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.