ATSB

Beech Aircraft Corp 76, VH-TTB

Safety Action

Company safety action

The company has undertaken to provide a fuel tank dipstick for the aircraft.

CASA safety action

Prior to this incident, the Civil Aviation Safety Authority (CASA) had released an NPRM (Notice of Proposed Rule Making), which, in part, deals with precautions before flight and fuel management, as part of the review of the Civil Aviation Regulations. CASA's intent is to introduce regulations that are simple and unambiguous.

The NPRM document contained the following proposed regulations:

'91.180 Precautions before flight

1. The pilot in command of an aircraft must, before flight, inspect the aircraft and review all factors relevant to the safety of the flight that can reasonably be assessed before departure.

2. When reviewing factors likely to affect the safety of the flight, the pilot in command of an aircraft must take such action as is reasonable to ensure that, before take-off, all of the following requirements are met:

k) sufficient fuel is on board the aircraft for it to land at the end of the flight with the required fuel reserves still on board;

l) the quantity of fuel in the aircraft's fuel tank or tanks has been checked by visual inspection or by 2 different methods.'

Significant Factors

The pilot did not establish the actual fuel quantity on board the aircraft prior to departure.
The aircraft fuel tanks contained insufficient fuel for the planned flight.
The right fuel quantity gauge transmitter unit was inoperative.

Analysis

The checks conducted by the pilot prior to the flight were inadequate to the extent that the pilot significantly over-estimated the quantity of fuel available for the flight.

The right engine failed due to insufficient fuel in the right tank while the aircraft was in a climb attitude. However, the pilot was apparently confused by the indications of the failure, as evidenced by his attempts to feather the propeller, but then continued with the propeller windmilling, on the assumption that some power was still available. This was despite readily available indications that the engine had failed. The pilot's apparent confusion was probably due to insufficient recurrent training in emergency procedures relevant to the aircraft type.

The pilot apparently over-relied on the tachometer and manifold pressure gauge indications, but lacked an understanding of those indications. Had the pilot recognised that the engine was not producing power, he may have persisted with his attempts and feathered the propeller. This would have increased the aircraft's performance by significantly reducing drag and should have permitted a greater degree of safety for the subsequent return to Essendon.

When the pilot manipulated the throttle lever of the failed engine as part of his engine failure confirmation checks, he should have realised that the engine had lost all power. The yawing of the aircraft as the pilot moved the pitch lever towards the feather position, due to reduced propeller drag, should also have provided a strong indication that the engine had failed.

With marginal aircraft performance, the pilot passed two suitable airfields and rather than divert to Moorabbin, continued to Essendon. This may suggest that fatigue, and possibly a desire to minimise inconvenience to the passengers and the operator adversely affected the pilot's judgement.

Summary

The pilot had planned to conduct a charter flight, with three passengers, from Essendon to Latrobe Valley, Vic. in a twin engine Beech Duchess aircraft. The pilot reported that he arrived at the Essendon airport about 90 minutes prior to the scheduled departure, carried out the daily inspection on the aircraft and submitted an instrument flight rules flight notification. He checked the aircraft maintenance release and the company fuel log that included the aircraft's last flight four days earlier. The pilot reported that he checked the two fuel quantity gauge readings which indicated a half-full tank and a slightly less than half full tank. He then visually checked the contents of the tanks relative to the '30 US gallon' metal tabs that are visible through the filler opening. He estimated that the fuel tanks contained a total of about 200 litres, but did not confirm this, as a fuel tank dipstick was not provided for that aircraft. The pilot's flight plan indicated that 128 litres of fuel, including reserves, would be required for the flight.

During the climb to the planned altitude of 7,000 ft, the right engine's power reduced. The pilot concluded that, from the engine tachometer reading of 1,500 revolutions per minute, and the manifold pressure indications, the right engine had partially failed. He carried out engine failure confirmation checks, but as the propeller pitch lever was very stiff, was unable to place it in the feather position. The pilot later reported that, during manipulation of the pitch lever, the aircraft had yawed significantly. Therefore, he decided to reset the right engine controls to a cruise setting because partial power was preferable to no power.

The aircraft was unable to maintain altitude so the pilot decided to return to Essendon. He requested an air traffic clearance from the Melbourne Approach air traffic controller (ATC) when the aircraft was about 50 NM east of Essendon. After receiving a clearance, and as he turned onto a westerly heading, the aircraft descended into cloud. At the pilot's request, ATC provided headings for the pilot to track further to the south to avoid the higher terrain on the direct track to Essendon. Lowest safe altitude (LSALT) is a published or pilot calculated minimum altitude that ensures terrain clearance during flight in instrument flight conditions. Flight below an LSALT altitude is only permissible during visual meteorological conditions or while conducting a published instrument approach. When the aircraft descended below the LSALT, ATC advised that a diversion to the closer Moorabbin airport, which was to the south east of Essendon and to the south of the aircraft, was available. That option would have allowed the aircraft to track over lower terrain and would have minimised the track distance over the Melbourne suburbs. However, the pilot decided to return to Essendon, where the operator's maintenance facilities were located and the passengers could be transferred to another company aircraft. After descending through the next LSALT step while in cloud, the aircraft descended into visual conditions about 21 NM east of Essendon at about 2,500 ft. The aircraft continued to descend until it stabilised in almost level flight at about 1,500 ft. The pilot then tracked direct to Essendon and carried out a visual approach and landing.

The pilot had bypassed two other suitable airfields, Lilydale and Coldstream, approximately 10-15 NM to the right of his track. The Civil Aviation Safety Authority (CASA) Civil Aviation Orders (CAO) 20.6 permitted the pilot of an aircraft with a failed engine to fly past a suitable aerodrome if another suitable aerodrome was available nearby and the pilot assessed that the aircraft could be flown safely to that aerodrome.

Company engineering inspection of the aircraft found that the right fuel tank, that was supplying the right engine when it lost power, contained no fuel. The right fuel quantity gauge transmitter unit was corroded and seized in a position that resulted in the gauge always indicating half-full. It was possible to feather the right propeller, although the pitch control was stiff.

The control cable and the fuel tank sender unit were subsequently replaced. The pilot commented that he had conducted a feather check as part of the pre-takeoff checks and although the right pitch lever was stiff to operate, he was satisfied that the propeller feathering mechanism was operating satisfactorily. The pilot later commented that the engine had failed due to fuel starvation and that he had not recognised the symptoms of a piston engine failure. He reported that he did not notice the reduced fuel pressure to the right engine until after the aircraft descended into visual conditions.

The aircraft's pilots operating handbook cautioned pilots against attempting to determine the inoperative engine by reference to the tachometers or the manifold pressure gauges and stated that those instruments often indicated near normal readings after an in-flight engine failure.

The pilot had recently resumed employment with the operator. He began his career with the operator and had flown as a first officer on F-27 turboprop aircraft for four years. He then obtained employment with a regional airline for two years as a first officer on turboprop aircraft, and had just completed line training as first officer on a jet aircraft when that airline suspended operations.

The day before the incident, the pilot had completed a 12-hour tour of duty, including 8.1 hours of flight time completing a co-pilot endorsement on a business jet. The two days prior to that had been spent on ground duties. He had 6-8 hours rest overnight at home and had risen early on the day of the occurrence. The pilot reported that he was tired on the day of the occurrence and that he had felt similarly for some time. He had been on duty for 16 consecutive days or a total of 159.4 hours duty time, primarily in a capacity unrelated to his employment as a pilot. Those additional duties were reflected in the pilot's recorded duty times.

The pilot had logged about 3,600 hours total flight time, including 600 hours in command on piston-engine aircraft. Those command hours consisted of about 200 hours twin-engine, of which 25 were in Duchess aircraft. All his other flying had been in turboprop and jet aircraft. During the three months preceding the incident, the pilot had flown approximately 70 hours, but had only flown the Duchess for three hours during that time.

The pilot's work/rest history for the four weeks prior to the incident was examined using a computerised fatigue algorithm developed by the Centre for Sleep Research, University of South Australia. The results indicated that the pilot was probably experiencing moderate levels of fatigue in the week leading up to, and on the day of the incident.

Occurrence summary

Investigation number	200200047
Occurrence date	17/01/2002
Location	93 km SE Melbourne, Aero.
State	Victoria
Report release date	23/01/2003
Report status	Final
Investigation type	Occurrence Investigation
Investigation status	Completed
Mode of transport	Aviation
Aviation occurrence category	Fuel starvation
Occurrence class	Incident
Highest injury level	None

Aircraft details

Manufacturer	Beech Aircraft Corp
Model	76
Registration	VH-TTB
Serial number	ME-359
Sector	Piston
Operation type	Charter
Departure point	Essendon, VIC
Destination	La Trobe Valley, VIC
Damage	Nil

Fairchild SA227-AC, VH-VEH

Safety Action

Local safety action

As a result of this occurrence, the aircraft operator has taken action to re-route the PTT wiring away from the circuit breaker supply bus and removed sharp edges from the panel housing to prevent wire chafing.

Summary

During cruise flight, the crew of the Metro III aircraft noticed a burning smell and smoke in the cockpit. The crew discovered that the problem was associated with avionics bus number 2, and isolated the bus. Following this action, the smoke and burning smell dissipated and the flight was successfully completed.

The investigation revealed that a short circuit had occurred in the right avionics bus circuit breaker panel and that the aircraft was being operated with a minimum equipment list item open for a faulty press-to-talk (PTT) for the co-pilot's audio system. Damage was sustained to insulation of the wiring and the bus link in the co-pilot's audio loom, including the PTT wires. The damage had resulted in a short circuit between the right avionics bus circuit breaker bus supply link, and the co-pilot's audio wiring loom. The wiring loom was physically secured to the circuit breaker busbar.

The damage to the insulation of the link wire was in the form of cuts, possibly from manoeuvring the right avionics bus circuit breaker access panel past sharp edges on the panel housing during routine maintenance. The insulation damage ranged in depth and in some areas exposed or damaged the copper conductor. There was also evidence of heat moulding from physical contact between the bus link and the co-pilot's audio wiring loom, due to excess current draw from the faulty PTT.

The routing of the PTT wiring loom ran along the circuit breaker busbar from the right avionics circuit breaker bus. Chafing against this bus may have caused the original PTT defect, and combined with the damage to the bus link wire, produced a short circuit from the bus link wire through to the earth wires in the co-pilot's audio wiring loom. The short circuit bypassed individual circuit breakers allowing a current draw of up to 100 amperes through the right essential bus 100 ampere circuit breaker switch.

Occurrence summary

Investigation number	200200029
Occurrence date	06/01/2002
Location	56 km NE Melbourne, Aero.
State	Victoria
Report release date	16/10/2002
Report status	Final
Investigation type	Occurrence Investigation
Investigation status	Completed
Mode of transport	Aviation
Aviation occurrence category	Smoke
Occurrence class	Incident
Highest injury level	None

Aircraft details

Manufacturer	Fairchild Industries Inc
Model	SA227
Registration	VH-VEH
Serial number	AC-663B
Sector	Turboprop
Operation type	Charter
Departure point	Canberra, ACT
Destination	Melbourne, VIC
Damage	Nil

Ayres Corp S2R-G10, VH-UDG, Moruya Aerodrome, New South Wales, on 7 January 2002

Summary

The Ayers Turbo Thrush aircraft was conducting water-bombing operations in support of bush fire-fighting activities. Three missions had been flown during the preceding 2 hours, using runway 05. Following the third mission, aircraft operations were suspended, and the aircraft was refuelled. During refuelling the pilot was tasked to drop a load of retardant in another location. The pilot assessed the wind to be from the northeast and lined up for departure on runway 05. The aircraft had a full load of retardant on board. The pilot reported that during the take-off roll he experienced control difficulties, so he jettisoned approximately half of the retardant load in order to assist with directional control of the aircraft. As the aircraft became airborne, it pitched nose-up and rolled right. The right wing collided with a sand dune and the aircraft cartwheeled onto the nearby beach, coming to rest in shallow water. The pilot, who was the sole occupant, egressed the aircraft uninjured. The aircraft was destroyed. A total of 25 minutes had elapsed between the take-off attempt and the preceding landing.

The pilot assessed that while the aircraft was heavy at the commencement of the take-off roll, it was approximately 300 kg below Maximum Take-off Weight. Jettisoning of approximately half the fire retardant load during the take-off roll further reduced the take-off weight.

The Terminal Area Forecast current at the time of the accident indicated a wind of 270 degrees at 15 kts. Recorded and observed meteorological conditions indicated strong gusty north-westerly winds.

The failure of the aircraft to become airborne while under control was consistent with a take-off attempt in a heavy aircraft under the influence of strong tail and crosswind components.

Occurrence summary

Investigation number	200200022
Occurrence date	07/01/2002
Location	Moruya, Aero.
State	New South Wales
Report release date	15/02/2002
Report status	Final
Investigation type	Occurrence Investigation
Investigation status	Completed
Mode of transport	Aviation
Aviation occurrence category	Collision with terrain
Occurrence class	Accident
Highest injury level	None

Aircraft details

Manufacturer	Ayres Corporation
Model	S2R
Registration	VH-UDG
Serial number	G10-110DC
Sector	Piston
Operation type	Aerial Work
Departure point	Moruya, NSW
Destination	Moruya, NSW
Damage	Destroyed

Boeing 767-238, VH-EAK

Safety Action

Local safety action

As a result of this occurrence, the third party maintenance organisation advised, 'As a preventative measure we have briefed our maintenance personnel to trim or adjust to mid band position when trimming or adjusting to a given band.'

Factual Information

Previous engine occurrences of this aircraft

4 January 2002 (ATSB occurrence report 200200017)

During the landing flare shortly before touchdown, the aircraft sustained a left engine flameout. The flight crew reported that the engine exhaust gas temperature (EGT) remained high and selected the left engine fuel control switch to the CUTOFF position and completed the landing. After a visual inspection by fire crews at a nearby taxiway, the aircraft was taxied to the terminal. The operator's maintenance personnel inspected the engine for damage or leaks, conducted idle and high power engine checks and completed electronic engine control unlock function checks. All engine parameters were found within limits and the aircraft was returned to service.

5 January 2002 (ATSB occurrence report 200200006)

The B767 aircraft had just completed the landing roll, when air traffic controllers in the tower noted fire coming from the left engine. They advised the flight crew of the situation and called for emergency services. The aircraft came to a stop on a nearby taxiway. By the time emergency services arrived the fire had extinguished. After a visual inspection by fire crews, the aircraft was taxied to the terminal. Maintenance personnel conducted troubleshooting using the engine manufacturer's troubleshooting procedures. The left engine fuel control unit and fuel pump were subsequently replaced. After completing test runs of the engine, the aircraft was returned to service.

Engine/component history

On 14 December 2001, third party contract maintenance personnel installed the left engine EVBC unit, part number 776555-7, serial number F10363. At the time of installation, the operator reported that the unit had accumulated 511,399 hours time since new, 506,732 cycles since new, 5,139 hours time since overhaul, and 3,315 cycles since overhaul. The operator also advised that their practice was to add 500,000 hours and cycles in order to identify units with unknown hours and cycles prior to induction into their maintenance control system. On 8 August 2001, the unit had been repaired by the manufacturer following removal to resolve a discrepancy of a thrust lever split, inability to close the 3.0 bleed valve and an EGT difference between engines of 120 degrees C.

On 30 December 2001, the engine was test run for three hours. The results of the engine run were documented and plotted on the appropriate engine documentation graphs. Those plots were examined and considered within prescribed limits. Having met all applicable parameters, the engine and aircraft were subsequently returned to service.

Following the 8 January 2002 occurrence, a review of the plotted data on the engine run sheets indicated that several plotted points fell slightly within the lower limits of the acceptable trim band. The EVBC was initially bench tested at the operator's facility but failed the testing and was then sent to the manufacturer for further examination. The operator reported that the manufacturer's testing confirmed that the EVBC and bleeds were operating out of tolerance. The unit was subsequently disassembled and overhauled.

Engine stall or surge

Gas turbine engines, under certain operating conditions, may stall or surge due to any condition where the flow of air from the compressor's inlet to its outlet was disturbed. This can result in uncommanded shutdowns, internal damage or reduced performance of the engine.

Engine compressor control system

The engine compressor control system (air scheduling) increased compressor stability during engine starts, transient and reverse thrust operations. The variable geometry stator vanes regulated airflow into and through the high-pressure compressor. At maximum power settings, the variable stator vanes were actuated to their maximum open position to permit the greatest airflow to the engine. At that time, during normal operation, the start bleed valves (controlled by a signal from the EVBC to the normally open bleed ring) were fully closed so that the compressor discharge air was delivered to the combustor and turbine sections.

During power reductions for landing, the engine compressor air scheduling to the left engine was incorrect. That resulted in disrupted airflow throughout the engine and subsequent stalling. The discrepancy in the air scheduling of the engine was due to the incorrect performance of the engine vane bleed control unit. This anomaly could also have resulted in excessive amounts of fuel for the power setting and contributed to the fire witnessed coming from the left engine exhaust as reported during the 5 January 2002 occurrence on this aircraft (see ATSB report 200200006).

Local safety action

Analysis

Summary

The flight crew of the Boeing 767-238 (B767) aircraft reported that on 8 January 2002, during the landing roll, the left engine RPM decayed as reverse thrust was selected. No surge of the engine was reported. The flight crew selected the left engine fuel control switch to the CUTOFF position and completed the landing. After a visual inspection by fire crews, the aircraft was taxied to the terminal with the left engine shutdown.

The operator removed the aircraft from service and conducted extensive troubleshooting of the left engine utilising assistance from the engine manufacturer. That troubleshooting led to the replacement of the left engine vane bleed control (EVBC) unit and the turbine temperature (TT2) sensor. Following a test flight, the aircraft was returned to service.

Further investigation revealed that the aircraft had recently undergone scheduled maintenance, which included replacement of the left engine EVBC. Prior to the occurrence, the aircraft had completed seven flight sectors since replacement of the EVBC.

Occurrence summary

Investigation number	200200018
Occurrence date	08/01/2002
Location	Sydney, Aero.
State	New South Wales
Report release date	29/10/2002
Report status	Final
Investigation type	Occurrence Investigation
Investigation status	Completed
Mode of transport	Aviation
Occurrence class	Incident
Highest injury level	None

Aircraft details

Manufacturer	The Boeing Company
Model	767
Registration	VH-EAK
Serial number	23305
Sector	Jet
Operation type	Air Transport High Capacity
Departure point	Melbourne, VIC
Destination	Sydney, NSW
Damage	Nil

Derailment of coal train EG37, Black Mountain, Queensland, on 1 July 2001

Final report

Executive summary

On 1 July 2001, loaded coal train EG37 derailed on Connors Range causing $A21M damage to rolling stock and infrastructure. The accident resulted in the derailment of 75 wagons and 2 electric locomotives and extensive damage to about 500 metres of track and overhead wiring. There were no injuries resulting from the accident.

The investigation into the accident determined that an extended loss of Locotrol radio signal at the top of the range and the failure of the back up safety mechanism in the train brake system triggered the event. The brake system failure was due to a stray O-ring lodged in the seat of the cut off portion of the Brake Pipe Control Valve. The braking of the train was consequently reduced to something less than half its normal capacity. This was insufficient to allow the driver to control the speed of the train down the range.

Queensland Transport acknowledges the efforts of the ATSB for chairing the panel and Queensland Rail for their professionalism and unlimited provision of technical expertise.

Occurrence summary

Investigation number	2001/003
Occurrence date	01/07/2001
Location	Black Mountain
State	Queensland
Report release date	01/10/2001
Report status	Final
Investigation type	Occurrence Investigation
Investigation status	Completed
Mode of transport	Rail
Occurrence class	Accident
Highest injury level	None

Collision between suburban electric passenger train 6369 and the empty express electric train 6371, Footscray, Victoria, on 5 June 2001

Final report

Executive summary

An empty suburban electric express train collided with the back of a suburban passenger train at number 4 platform Footscray station just after 0828 on 5 June 2001. The passenger train had about 20 people on board.

The emergency services, including the Police, Fire and Ambulance services attended the scene. As both trains and the rail infrastructure were operated by Bayside Trains, a subsidiary of National Express, the National Express emergency plan was implemented.

The driver of the empty train suffered an injury to his left elbow. Two passengers were taken to hospital for observation but were released with no serious injury.

The evidence available to the investigation suggests strongly that the driver's performance was impaired by a medical condition leading to him being unable to recall events for a period of less than two minutes, between the Maribyrnong River bridge and the point of collision. The driver was taking a course of prescribed medication, which combined with the early start to his working day on the morning of the accident and a history of chronically disturbed sleep, may have resulted in a sleep period (apnoeic episode) while he was driving the train.

There are safeguards or defences to protect against such an eventuality. On this occasion the defences in place failed to prevent the accident. A number of defences were identified as being inadequate in terms of design or application.

The investigation established that the maintenance of the trains was not a factor in this accident. The signalling system and automatic train stop operated within their design criteria. The design criteria of the signal and train stop systems, however, were such that the system could not prevent the collision given the speed of the train involved.

Drivers of suburban trains are required to maintain a given pressure on either a hand or foot pedal 'pilot valve', often referred to as a 'dead-man's handle'. In the event of a driver becoming incapacitated for any reason, the relaxing, or increase of pressure on the pilot valve should automatically apply the train brakes. Examination of relevant literature shows that pilot valves can be intentionally or inadvertently circumvented. In certain circumstances, the foot pedal can be maintained at the correct pressure just by the weight of the lower leg, whether or not the driver is incapacitated. Recommendation 7, below, is made in the full understanding that alternative systems, such as vigilance controls, may not be as effective in a metropolitan rail system, given the density of traffic, the time gap between trains and the workload of train drivers.

The alertness and fitness of drivers to perform their duties is also a defence against accident. While the investigation did not identify any significant defect with driver training, it did find serious defects in the monitoring of driver's health and fitness to operate mass public transport vehicles. The report concludes that the driver of the express train, although experienced and skilled, should not, on medical grounds, have been permitted to drive.

The investigation established that there was a lack of communication and coordination between those responsible for driver management and health professionals. The health standards used to assess driver fitness were themselves deficient.

The report's recommendations are:

Medical standards should be reviewed and amended to:

better monitor drivers' health and ensure a full past history and current medication regime is recorded, including monitor self medication of over-the counter and non prescription medication.
include an appropriate assessment of the current physiological and psychiatric status of all drivers to ensure operators have all relevant information on which to base an informed decision on driver fitness;
include a system to identify drivers 'at potential risk', with provision for monitoring ongoing fitness;
ensure that medical examination periods are strictly adhered to and drivers suspended if not holding current medical license;
require drivers to produce proof of medical fitness at any time;
create an audit system that will allow confirmation of compliance with such standards.

The medical examination procedures should be reviewed to manage any perception of a conflict of interest in the future medical fitness system and considers whether such examinations should be conducted by a panel of doctors appointed by, and responsible to, the Accreditation Authority.
Australian Standard, AS 4292 should be reviewed in respect of the monitoring of the health and fitness of rail safety staff.
The signalling system and overlap should be reviewed with a view to ensuring, to the extent practicable, that trains passing a signal at danger are stopped within a safe distance. In sections before a station this distance would ensure a train is brought to a halt before a possible collision with another train stopped at the station.
The anti-collision posts on motor cars on Com Eng trains should be further investigated to identify any deficiency in their design.
Rail accident response plans should be reviewed to provide procedures to ensure immediate safety of the track infrastructure, training for station staff at manned stations in immediate response procedures and rapid deployment of staff at unmanned stations.
The use of hand and foot pilot valves should be reviewed, given their limitations, to determine whether the system can be made more effective or whether an alternative, equivalent system might make a better safeguard.
The train system radio network should be reassessed for radio reliability.

Copies of the report are available from the Victorian Department of Infrastructure's Customer Service Centre, Plaza Level, 80 Collins Street, Melbourne or by telephoning (03) 9655 8830.

Occurrence summary

Investigation number	2001/002
Occurrence date	05/06/2001
Location	Footscray
State	Victoria
Report release date	20/12/2001
Report status	Final
Investigation type	Occurrence Investigation
Investigation status	Completed
Mode of transport	Rail
Occurrence class	Accident
Highest injury level	Serious

Derailment of passenger train 8622, Sydney - Melbourne daylight XPT service, Wodonga, Victoria, on 25 March 2001

Final report

Executive summary

At 0743 on 25 April 2001, the Countrylink XPT daylight service ST3 (train 8622) left Sydney bound for Melbourne. The train consisted of a lead power car followed by seven passenger cars designated from 'A' through to 'G' and a trailing power car. On board the train was a crew of five- the driver, a passenger service supervisor and three passenger attendants- and 127 passengers.

The run from Sydney south was routine. No problems were reported at the driver changeover in Junee at approximately 1354. At 1528 the train arrived in Albury where the passenger service supervisor and three passenger service attendants changed over. The train departed from Albury Station at 1532, approximately 30 minutes late, with 98 passengers on board.

After leaving Albury Station, the driver accelerated to 80 km/h and maintained that speed until approaching the Melbourne end of the Wodonga coal sidings, where he reduced the train speed to slightly below the 40 km/h posted speed. Shortly after this, the train passed the Hovell Street level crossing in Wodonga and continued to round the tight right-hand curve in the main line before the High Street level crossing. The train's speed was approximately 25 km/h. As the train entered this section of curve, the driver applied some power to maintain the train's speed through the curve.

At approximately 1538 at 301.1086 km, the inner wheel on the lead axle of the lead bogie (NHA 198B) of car 'E' (XF 2214) dropped from the low rail of the curve. At 301.105 km the inner wheel dropped completely from the low rail into the track fourfoot. The train travelled approximately 2.75 m further until the outer wheel on the same axle climbed over the high rail and onto the ballast shoulder on the outside of the curve. At 301.0911 km the trailing wheel-set of the bogie also derailed with the outer wheel climbing over the high rail and the inner wheel simultaneously dropping into the four-foot. The bogie, now completely derailed, travelled in this condition for approximately 950 m until the train was brought to a stop by the driver. The driver had stopped the train in response to a passenger emergency alarm which had been initiated by the passengers in car E.

The derailment occurred on the sharpest curve on the main line between Sydney and Melbourne. The alignment at this point in the main line was originally dictated by the presence of a crossing diamond where the broad gauge branch line to Bandiana had crossed the standard gauge main line. The alignment of the curve had not been changed since the closure of the branch line and the removal of the diamond in 1997.

Assessment of the track at the derailment site revealed a number of factors which contributed to the derailment, the most significant of which was the condition of the high rail fasteners which resulted in gauge widening of up to 49 mm at the point of derailment.

The derailment was unusual in some ways as there had been other freight and passenger train traffic on the line earlier in the day without incident. In addition, the derailment involved only one bogie in the middle of the train with bogies in the same train passing safely over the site before and after bogie NHA 198B had derailed. This indicates, that while the track-based elements were the primary causal factors, it was the combination of the vehicle-based and track-based factors that caused the derailment.

Inspection of the bogie which derailed revealed some factors which contributed to the derailment including a thin flange on the number-1 wheel and the poor condition of the bogie's side bearer yaw friction pads.

Occurrence summary

Investigation number	2001/001
Occurrence date	25/04/2001
Location	Wodonga
State	Victoria
Report release date	16/12/2002
Report status	Final
Investigation type	Occurrence Investigation
Investigation status	Completed
Mode of transport	Rail
Occurrence class	Accident
Highest injury level	None

Lifeboat accident and injury to crew aboard Cape Kestrel

Final report

Summary

At 1915 on 11 October 2001 the Panama flag bulk carrier Cape Kestrel, in ballast, anchored off the port of Dampier, Western Australia, waiting for a berth to load a cargo of iron ore for China. The next morning, the master decided to conduct a lifeboat drill and to lower the port lifeboat to the sea. Since the vessel was to berth port side to the ore loader, his intention was to also lower the starboard boat while alongside.

At about 0845, the boat, with the mate and four crewmembers on board, was lowered to the water where the hooks were disengaged. The release mechanism for the boat was checked and the engine was run ahead and astern. When the hooks were reconnected, a seaman on deck operated the remote control to recover the boat.

The remote control, however, did not start the winch motor, and the mate asked the first engineer, who was on deck at the time, to hoist the boat. The first engineer went to the starter panel for the lifeboat winches, located in the air conditioning room aft in the accommodation, and started the winch by manually depressing the main contactor for the motor.

Hoisting was stopped at the main deck, where the master, who had been watching from the bridge wing, ordered the mate to arrange for the occupants of the boat to disembark before swinging the boat in. The mate replied that the boat was too far from the deck for people to disembark safely and that it could be hoisted to the boarding platform with its crew on board.

Despite the master's protests, hoisting of the boat resumed with the first engineer depressing the contactor in the starter panel. The davits came in, past the limit switches and up against the stops, with the winch still running. The forward fall parted, followed by the after fall, causing the boat to fall about 20 metres to the water. Four crew members in the boat were injured, three of them seriously.

The mate's injuries were the most serious and he was taken ashore by pilot boat. He was examined at the hospital at Karratha and transferred to a hospital in Perth for treatment.

Three other crewmembers in the boat were taken ashore by helicopter for treatment at the hospital at Karratha. Two of them were repatriated after treatment, while the remaining crewmember rejoined the ship before it sailed. The bosun, who had also been in the boat, suffered only bruising to his forehead.

The boat was later recovered. New falls were fitted to the davits and cracks in the boat were repaired. Broken windows were scheduled for repair at the earliest opportunity.

The Panama Maritime Authority authorised the vessel to sail for a period of 30 days until 12 November 2001 while repairs to the boat were arranged, provided that liferafts of the same capacity were provided on board. Before the vessel sailed from Dampier, a suitable liferaft was fitted on board.

Occurrence summary

Investigation number	173
Occurrence date	12/10/2001
Location	Dampier
State	Western Australia
Report release date	27/08/2002
Report status	Final
Investigation type	Occurrence Investigation
Investigation status	Completed
Mode of transport	Marine
Marine occurrence category	Lifeboat
Occurrence class	Incident
Highest injury level	Serious

Ship details

Name	Cape Kestrel
IMO number	9036014
Ship type	Bulk carrier
Flag	Panama
Departure point	Dampier, WA
Destination	China

Ballast tank explosion and fatalities on board Nego Kim

Final report

Summary

At about 0200 on Saturday 17 November 2001, the Hong Kong registered bulk carrier Nego Kim arrived at the port of Dampier and anchored to await berthing instructions. The ship, which was on a time charter to load a cargo of scrap iron at Fremantle, Adelaide and Dampier, for discharge in Singapore, remained at anchor through Saturday and Sunday. At anchor, the crew continued tasks from the ship's planned maintenance schedule, including the preparation of the interior of no.1 port topside ballast tank for painting.

On Sunday morning the crew performed some routine cleaning tasks. At about 1300, the mate monitored no.1 port topside ballast tank for oxygen content in accordance with safe entry procedures. At about 1430, the eight-man deck crew started work painting the steelwork inside the tank. One man was engaged in painting with an airless spray gun while the other deck crew maintained the paint reservoir, tended a cargo light lowered through the after manhole and assisted the painter as required. An open-ended compressed air hose was led from the forecastle, along the deck and down through this after manhole, while an electrically driven fan was positioned at an angle over the after manhole, which also provided access for the paint hose, light cable and a lanyard.

The mate supervised the initial stages of the task. The paint used was a two-part epoxy mix, thinned as needed using the thinner product supplied by the paint manufacturer. According to the mate, the volume of thinner used was between 30 and 50 per cent of the total mixture.

At about 1530 the mate went to the bridge to start his 1600 to 2000 anchor watch, leaving the bosun and deck fitter in charge at the site.

At about 1640 a large explosion ripped through the tank. The tank ruptured and three men were blown down the length of the main deck, killing them all instantly. The explosion also blew four other men over the ship's side. One man, who had been inside the tank, was still alive although severely burned. He was assisted out of the tank, through the ruptured main deck plating, and later airlifted ashore. Eighteen days later he died in hospital as a result of his burns and other injuries.

A search and rescue operation was initiated, using various surface vessels and aircraft as they became available, in the hope of finding the four men who had been blown overboard. The body of one of the men was recovered from the water at about 1325 the next day, 19 November. The search was continued until last light on 21 November, but none of the other three crew were found.

The report recommends safety actions to improve the ISM documentation carried on ships to include clear instructions for all operations in enclosed spaces and guidance on the conditions under which work in enclosed spaces should be undertaken. Recommended safety actions are also directed to the Dampier Port Authority with regard to an emergency response plan.

Occurrence summary

Investigation number	174
Occurrence date	18/11/2001
Location	Dampier
State	Western Australia
Report release date	22/10/2002
Report status	Final
Investigation type	Occurrence Investigation
Investigation status	Completed
Mode of transport	Marine
Marine occurrence category	Fatality
Occurrence class	Serious Incident
Highest injury level	Fatal

Ship details

Name	Nego Kim
IMO number	8507535
Ship type	Bulk carrier
Flag	Hong Kong
Departure point	Dampier
Destination	Singapore

Fire on board Captain Aysuna en route to Tasmania

Final report

Captain Aysuna

Captain Aysuna is a 5-hatch, geared, Panama flag bulk carrier. The vessel, built at the Usuki Iron Works Ltd in Saiki, Japan in 1985, is classed with Nippon Kaiji Kyokai. It is owned by Hydale Trading Corporation and, at the time of the incident, was on time charter to BHP Transport and Logistics Pty Ltd.

The vessel has a length overall of 168 m, a beam of 27 m and a depth of 13.45 m. It has a gross tonnage of 16 080 and a summer deadweight of 26 914 tonnes at a draft of 9.547 m. Captain Aysuna is powered by a Mitsubishi 6 UEC52LA slow speed diesel engine delivering 5 279 kW to a single, fixed pitch, propeller, giving the vessel a service speed of 13.5 knots.

The vessel had a crew of 24, comprising 19 Bulgarian and two Indian nationals, a Russian, a Yugoslav and a Turk.

Conclusions

There was a definite and concerted attempt by members of the crew not to cooperate with the investigation. The area affected by the fire was cleaned and painted over in an attempt to hide all evidence of the cause of the fire, and, while the crew almost certainly knew what had caused the fire, they did not divulge this information to the ATSB.

It is probable that the fire was caused by spillage of a small amount of fuel from a container left at the forward edge of the boiler flat. The fuel, probably being used as a cleaning medium, could have spilled as a result of movement of the ship in rough seas. It is likely that this fuel was diesel oil.

The fire, while it produced a quantity of flame and smoke, only caused minor paint damage and did not cause any damage to machinery.

Occurrence summary

Investigation number	172
Occurrence date	08/10/2001
Location	Bass Strait
Report release date	26/08/2003
Report status	Final
Investigation type	Occurrence Investigation
Investigation status	Completed
Mode of transport	Marine
Marine occurrence category	Fire
Occurrence class	Incident
Highest injury level	None

Ship details

Name	Captain Aysuna
IMO number	8515843
Ship type	Bulk carrier
Flag	Panama
Departure point	Newcastle, NSW
Destination	Hobart, Tas

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