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.

On 9 July 2009, a Cessna 208B Grand Caravan aircraft registered VH-TFS, was being operated on a charter passenger flight from Lizard Island, Queensland (Qld) to Cairns, Qld. The flight was being conducted under instrument flight rules. At about 1250 Eastern Standard Time, the aircraft encountered severe turbulence. The pilot and two of the three passengers sustained minor injuries. The flight continued to Cairns and landed without further incident.

The Australian Transport Safety Bureau publication 'Staying Safe against In-flight Turbulence' (2009) provides some useful information on aircraft turbulence events. A full copy of that publication is available here.

Interim Factual report released 22 November 2005

At 1828 Eastern Standard Time on 11 October 2005, a Kawasaki Heavy Industries BK117 B-2 multi-engine helicopter, registered VH-BKS, was being operated on a night Visual Flight Rules (VFR) flight to Maroochydore, Qld. The pilot had flown the helicopter on a medical flight from Maroochydore to Brisbane's Princess Alexandria Hospital earlier that evening and was repositioning to Maroochydore with the paramedic and crewman on board.

The pilot intended to fly direct to Maroochydore, VFR on top of scattered¹ cloud at 4,500 ft. Soon after reaching 4,000 ft, the pilot noted that the cloud along the intended track was 4 OKTAS below the level of the helicopter. However, shortly after, the pilot observed the weather as solid overcast beneath him. He reported that the Brisbane approach controller subsequently advised him that the weather at Maroochydore had deteriorated to broken cloud at 1,000 ft above ground level (AGL).

The pilot continued with the flight to Maroochydore and conducted a Maroochydore runway 36 VOR/DME² approach in Instrument Meteorological Conditions (IMC). The helicopter was not equipped for single-pilot Instrument Flight Rules (IFR) operations, nor was the pilot the holder of a current Command Multi- Engine Instrument Rating (Helicopters).

The pilot reported that he did not return to Brisbane because the Brisbane Approach controller made a broadcast to all aircraft inbound to Brisbane 'that an Instrument Landing System (ILS) approach was mandatory'. He said that he assumed this to mean he would have to conduct an IFR approach he was unfamiliar with. He did not declare an emergency. The pilot was an experienced ex-military pilot, with extensive IFR experience. He reported entering cloud at 2,600 ft and broke visual during the approach at 760 ft. The IFR minimum descent altitude for that approach was 660 ft. The pilot reported landing with 45 minutes usable fuel remaining.

Area forecasts indicated that, for the planned flight, VFR operations were possible. The pilot planned the flight using a TAF (Terminal Aerodrome Forecast) for Maroochydore that was valid from midday to midnight on the day of the occurrence. That TAF indicated visibility greater than 10 km and scattered cloud at 2,500ft. The pilot assessed this as suitable for VFR.

An amended TAF for Maroochydore valid from 1800 that evening through to 0600 the following morning, was issued by the Bureau of Meteorology at 1626. That TAF indicated visibility greater than 10 km, few³ clouds at 1,000 ft and scattered cloud at 2,500 ft. The pilot reported he did not have the amended TAF and did not access further weather information after 1400 because he had assessed, during the preceding flight to Brisbane, that the weather was suitable for a return VFR flight to Maroochydore.

1. Defined as 3 to 4 OKTAS (unit of visible sky area representing 1/8 of the total area visible to the celestial horizon).
2. VHF Omni-directional radio range/Distance Measuring Equipment.
3. Defined as 1 to 2 OKTAS.

On 21 December 2007, an Evektor Sportstar, Recreational/ Light Sport Aircraft registration 24-4148 was involved in a fatal accident 12 km SE of Bindoon ALA. Recreational Aviation Australia (RA-Aus) staff commenced an investigation into the occurrence. Three Global Positioning System (GPS) units were recovered from the accident site.

On 9 April 2008, RA-Aus requested technical assistance from the Australian Transport Safety Bureau (ATSB) to recover the data from the GPS units. No analysis of the data by the ATSB was sought by RA-Aus. To protect the information supplied by RA-Aus and the investigative work undertaken to assist RA-Aus, the ATSB initiated an investigation under the Transport Safety Investigation Act 2003.

Data was successfully recovered from all three GPS units in May 2008 by ATSB Technical Analysis staff and subsequently provided to RA-Aus investigators.

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

Abstract

At about 0542¹ on Tuesday 22 April 2008, empty southbound manganese ore train 3DM4 derailed four wagons approximately 58 km south of Darwin near Manton Dam in the Northern Territory (NT).

There were no injuries as a result of the derailment but there was minor damage to the track and rolling stock.

The investigation found that the draft key² on the leading end of the 31st wagon had dislodged from the coupler shank, which allowed the coupler to withdraw and fall onto the track. As a result of this the train was separated into two portions; 30 wagons that were still coupled to the locomotives and the 14 following wagons which were detached. The detached portion of the train then almost certainly passed over the dislodged coupler that was lying on the tracks leading to the derailment of four wagons.

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1. The 24-hour clock is used in this report to describe the local time of day, Central Standard Time (CST).
2. Also known as 'Murray Key', the draft key is a flat steel bar that passes through the underframe, yoke and coupler. Its primary function is to secure the yoke and coupler as a unit within the underframe.

Rail safety recommendation

[RR2008-006-SR-007]