Executive summary

At 1706 hours on 18 August 1999 the Indian Pacific passenger train No. 3AP88,Adelaide to Perth, was inadvertently directed onto the loop line at Zanthus where afreight train, No. 3PW4N, Perth to Whyalla was standing and as a consequence a lowspeed collision occurred between the two trains. The collision resulted in seventeenpassengers and four train crew members being conveyed to Kalgoorlie Hospital by theRoyal Flying Doctor, luggage/smoking lounge car HM311, on the Indian Pacificpassenger train derailing and sustaining extensive damage and significant damagesustained to locomotives NR51, NR15 and passenger coaches. The east west rail linkat Zanthus was closed to train operations until 1305 hours on August 19, 1999.

At the time of the collision, there were one hundred and eighty one (181) passengers, sixteen (16) Great Southern Railway On Train staff and five (5) Train Crew (drivers)on the two (2) trains. Thirty one (31) passengers and fourteen (14) On Train staff have reported sustaining some injury or side effects. Of the twenty one (21) persons conveyed to Kalgoorlie Hospital by the Royal Flying Doctor, only two (2) were held in hospital overnight for observation. One remained in hospital subsequently for some weeks.

There was no damage incurred to track and infrastructure.

The Indian Pacific Passenger train 3AP88 is owned and operated by Great Southern Railway using locomotives and locomotive crews provided on a "Hook and Pull" contract with National Rail Corporation. Freight service 3PW4N is operated by National Rail Corporation.

Australian Rail Track Corporation owns the track section and provides Train Control management from the Adelaide Control Centre. The train management safe working system in operation over the section of line is a Train Order System. Mainline to loop points are fitted with electric points motors, equipped with mechanical point indicators and coloured light indicators, which are activated locally by push button switches provided in a control box at the equipment room.

The investigation found that the collision resulted from a crew member of train3PW4N operating a push button control, as 3AP88 approached the points, altering the setting of the main line points from normal to reverse diverting train 3AP88 on to the loop. There was no mechanical or electrical interlocking system to prevent the movement of the points in front of the approaching train.

Procedural measures have been instituted to prevent a similar occurrence in the short term pending completion of a system upgrade being undertaken by Australian RailTrack Corporation. The system upgrade will provide a time interlock designed to prevent the movement of the points for a precise period related to the stopping time for an approaching train. The upgrade programme has commenced and is expected to be completed by December 1999.

The pilot reported that shortly after commencing the take-off roll the Metroliner began tracking to the right of the runway centreline. The crew discontinued the take-off, taxied back to the end of the runway and subsequently completed a normal take-off. In both instances, the nosewheel steering had not been engaged.

The operations department of the company believed that the aircraft had been modified in accordance with a service bulletin that prohibited the use of nose-wheel steering for take-off and landing. A check of documentation following the incident revealed that the modification had not been installed in the aircraft. The correct procedure in this case was for the nosewheel steering to be engaged for take-off.

The Australian Transport Safety Bureau (formerly the Bureau of Air Safety Investigation) recommends:

R20000046

Australian aircraft operators consider the introduction of formal pushback tractor training and competency standards, which includes all varieties of equipment utilised, and regular recurrent proficiency checks of all pushback tractor drivers.

R20000047

Australian aircraft operators evaluate pushback tractor safety controls for standardised design and location across the fleet, particularly in regard to the International Air Transport Association (IATA) requirements.

LOCAL SAFETY ACTION

Although the operator currently has no requirement for recurrent testing of drivers on each particular vehicle for which an airside licence is held, its Airport Services Department is presently addressing this aspect.

Local safety action

Following this incident, the operations manager said he would plan a company training program to reinforce aircrews' obligation to follow aircraft emergency checklist actions

As a result of this occurrence, the Australian Transport Safety Bureau (formerly BASI) made the following recommendations:

[ R20000004 ] - The Australian Transport Safety Bureau (formerly the Bureau of Air Safety Investigation) recommends that Rolls Royce Commercial Aero Engine Limited notify all operators using Rolls Royce RB211-524D4 or similar engines of the possibility of failure of the cold stream nozzle during operation.

[ R20000005 ] - The Australian Transport Safety Bureau (formerly the Bureau of Air Safety Investigation) recommends that the United Kingdom Civil Aviation Authority notify all operators under their jurisdiction using Rolls Royce RB211-524D4 or similar engines, of the possibility of failure of the cold stream nozzle during operation.

[ R20000006 ] - The Australian Transport Safety Bureau (formerly the Bureau of Air Safety Investigation) recommends that the US Federal Aviation Administration notify all operators under their jurisdiction using Rolls Royce RB211-524D4 or similar engines, of the possibility of failure of the cold stream nozzle during operation.

[ R20000007 ] - The Australian Transport Safety Bureau (formerly the Bureau of Air Safety Investigation) recommends that Rolls Royce Commercial Aero Engine Limited review Rolls Royce RB211-524D4 engine cold stream nozzle inspection criteria to minimise the possibility of failure during operation.

[ R20000008 ] - The Australian Transport Safety Bureau (formerly the Bureau of Air Safety Investigation) recommends that the United Kingdom Civil Aviation Authority review Rolls Royce RB211-524D4 engine cold stream nozzle inspection criteria to minimise the possibility of failure during operation.

[ R20000009 ] - The Australian Transport Safety Bureau (formerly the Bureau of Air Safety Investigation) recommends that the US Federal Aviation Administration review Rolls Royce RB211-524D4 engine cold stream nozzle inspection criteria to minimise the possibility of failure during operation.

[ R20000010 ] - The Australian Transport Safety Bureau (formerly the Bureau of Air Safety Investigation) recommends that the Civil Aviation Safety Authority review Rolls Royce RB211-524D4 engine cold stream nozzle inspection criteria to minimise the possibility of failure during operation.

The pilot of the Cessna 172R had planned a private flight, with three friends, from Moorabbin via Williamstown, Laverton, Melton and Torquay before returning to Moorabbin. Before departure, the pilot arranged for the fuel load on the aircraft to be adjusted in order to ensure that the aircraft did not exceed its maximum allowable weight limit. The aircraft departed Moorabbin at about 1350 Eastern Summer Time.

Witnesses, including some with relevant aviation experience, reported seeing the aircraft conducting steep turns south of Melton township, north-east of Melton aerodrome, north of Gisborne and in the vicinity of the accident site. This information is consistent with photographs taken from the aircraft during the flight.

Radar information indicated that between 1432 and 1435, the aircraft was flown in a sequence of left turns through 360 degrees in the vicinity of the accident site. These turns were conducted at an altitude of between 1,900 ft and 2,300 ft above mean sea level (approximately 550 to 950 ft above ground level).

Witnesses reported that after completing two 360 degree left turns in the vicinity of the accident site, the aircraft headed north and adopted a nose-high attitude before entering a steep turn to the left. Most of the witnesses, including an experienced pilot, described seeing the aircraft's bank angle steepen as it passed a westerly heading and then the nose dropped such that the aircraft was heading approximately south in a near vertical, nose-down attitude. However, one witness described seeing the aircraft roll in a right-wing-over-left manoeuvre before it pitched nose-down.

One witness reported seeing the aircraft spiral to the ground however most witnesses saw it descend straight to the ground in a nose-down, near vertical attitude. Witness reports and wreckage evidence indicated that the aircraft impacted the ground heading approximately south and in a nose-down, right wing low attitude. The aircraft, which was destroyed by the impact, came to rest approximately 27 m from the initial impact point. There was no fire. The occupants received fatal injuries.

The wreckage was located in a paddock approximately 400 m north of the Gisborne-Kilmore Road, approximately half-way between Gisborne and Riddells Creek. The residence of one of the passengers was less than 1 km from the accident site. The elevation of the accident site was about 1,350 ft and Mount Macedon (3,284 ft) was 11 km to the north-north-west. The damage indicated that the engine was producing power and that the flaps were extended to approximately 10 degrees at the time of impact. The investigation did not identify any pre-existing defects that could have affected the operation of the aircraft.

Coordinated use of aileron, elevator and rudder controls will ensure that an aircraft maintains balanced flight. Discussions with the US Federal Aviation Authority (FAA) indicated that the Cessna 172 aircraft will exhibit mild stall characteristics if the aircraft stalls during balanced flight, and a pilot can regain control of the aircraft with a minimal loss of height. Most aircraft would require significantly more height above the ground to allow a pilot to recover control following a stall during unbalanced flight.

The Cessna Integrated Flight Training System Manual of Flight stated that a stall during a steep turn will result in a sharp nose and wing drop and that recovery actions must be prompt and precise.

The pilot held a private pilot licence and was endorsed on the aircraft type. He had completed spin recovery training, however the training was conducted in a different aircraft type. The pilot had accrued approximately 68 hours total flying experience. The post-mortem and toxicological examination did not identify any pre-existing conditions that could have affected the pilot's ability to fly the aircraft.

At the time of the accident the prevailing weather conditions were fine with scattered high level cloud. The Kilmore Gap automatic weather observation taken at 1430 indicated that the wind was 340 degrees at 19 kts gusting to 27 kts. The observation taken at Melbourne's Tullamarine airport at 1431 indicated that the wind was 360 degrees at 15 kts gusting to 27 kts and that the temperature was 33 degrees Celcius. During strong, gusting wind conditions such as existed at the time of the accident, hills and mountains can induce severe turbulence and downdraughts.

The aircraft was probably operating in turbulent conditions at the time of the accident, given the location of Mount Macedon upwind of the accident site. The manoeuvre described by witnesses was consistent with the aircraft stalling during the steep left turn. It is likely that the aircraft's reduced performance in the ambient temperature and the gusty and turbulent conditions contributed to the stall. In addition, the turbulent conditions would have made it very difficult for the pilot to maintain the aircraft in balanced flight during the sequence of steep turns. The loss of control following the stall and the pilot's failure to recover control in the height available was consistent with the stall occurring during unbalanced flight.

The student pilot was being tested in an RV-6 aircraft, registered VH-YGH, for the issue of a private pilot's licence. Witnesses reported that the take-off and initial climb appeared to be normal until about 500 ft above ground level when the aircraft's engine noise appeared to cease. The aircraft was observed to maintain a wings level attitude for a short distance before commencing a steep descending turn to the left. The aircraft contacted the top of several trees, rolled inverted and impacted the ground. Both occupants sustained serious injuries and the aircraft was destroyed.

Witnesses reported that the weather at the time was fine, "slightly cloudy" and with a south-easterly breeze.

The instructor reported that he had called for a simulated engine failure at about 300 ft above ground level. The student pilot closed the throttle and altered heading about 40 degrees, seemingly towards a nearby open field. He then indicated to the instructor that he was at 500 ft and would return to the runway. The instructor had previously noted that when the aircraft's altimeter read 500 ft, because the airfield elevation was 130 ft AMSL, the actual height above the runway was about 300 ft. As the instructor was looking back to check the relative position of the runway, the aircraft's nose and left wing suddenly dropped. The instructor took the controls and recovered the aircraft to a wings level attitude, however there was insufficient height remaining to prevent contact with the trees.

The student pilot was not able to remember any details of the accident flight beyond the take-off and initial climb.

The reported evidence is consistent with the aircraft stalling during an attempted turn to land on the reciprocal of the take-off runway, following a simulated engine failure.

The Australian Transport Safety Bureau (formerly BASI) did not conduct an on-site investigation into this accident.

The student pilot hired a Cessna 150L aircraft to undertake a local training flight with an instructor. The aircraft departed Canberra airport at approximately 1705 Eastern Summer Time and proceeded directly to the training area. The aircraft entered the circuit area for a landing at Canberra about 1.2 hours later. At that time, the pilot was instructed by air traffic control to track the aircraft in order to position it on a left downwind leg for a landing on runway 12. However, the controller observed the aircraft positioning for a right downwind leg. The controller instructed the pilot to turn left onto a heading of 090 degrees to reposition for a left circuit. Following the turn, the student pilot and instructor observed a decrease in engine power. The instructor resumed control of the aircraft and attempted to diagnose the loss of power. The engine surged a number of times and then lost power entirely, including stoppage of the propeller. The instructor transmitted a mayday message, and was cleared by the controller to track for the closest runway. When it became apparent that the aircraft would not reach the runway, the instructor changed heading and was manoeuvring to land in a field when the aircraft struck a tree and impacted the ground.

Both occupants were injured in the accident, but vacated the aircraft through the left door. There was no post-impact fire. The instructor died seven days later as a result of complications associated with injuries suffered in the accident.

Before the flight, the instructor had dipped the fuel tanks and ascertained that the aircraft contained 40 L of useable fuel, with 4 L more in the right tank than the left tank. The fuel tanks are interconnected and are intended to allow fuel to self-level. It is not possible to select fuel from individual tanks during flight.

Examination of the wreckage indicated that the aircraft had impacted the ground in a nose-down attitude. The engine was not operating at the time of the impact and the propeller was stationary. The aircraft was considered to have been capable of normal operation before impact.

The fuel tanks were found to be intact. However, the fuel and cross-vent plumbing on the right tank was disrupted during the impact sequence. That disruption would have prevented fuel from transferring between tanks following the accident. There was no indication of a fuel spill at the accident site. The left fuel tank was found to contain no fuel, and the right tank was found to contain 12 L. Advice from the manufacturer and the owner's manual indicated that the unusable fuel for that aircraft was 11.4 L, which is spread throughout the fuel system (including the two tanks). No defect was found in the fuel system that would have caused a difference in the quantity in the fuel tanks or the engine power loss. Nor were any defects found in the fuel gauges or their respective sender units.

At the time of the engine failure, the aircraft had been airborne for about 1.2 hours. During the exercise, the instructor and student engaged in steep turning exercises at 45 and 60 degrees bank angle, and in spiral dive and incipient spin recovery. The instructor also demonstrated how to configure the aircraft to commence a loop, which was conducted at 5,500-6,000ft. Much of the lesson would have required the use of full power to achieve the desired performance.

The owner's manual indicated the fuel consumption for a 75% power setting to be 22 L/h. Company policy was to plan for 22 L/h. An engine manufacturer's representative indicated that a fuel consumption of 33.4 L/h could be expected when operating the aircraft at the full-power setting.

An aircraft manufacturer publication titled "Pilot Safety and Warning Supplements" cautions pilots regarding uncoordinated flight for longer than 30 seconds when the fuel tanks are less than one-quarter full. The publication indicates that the aircraft is considered to be in uncoordinated flight when the balance "ball" on the turn coordinator instrument is displaced more than one quarter from its centre position. Uncoordinated flight may result in an interruption of the fuel supply to the engine.

The instructor held a commercial pilot licence and a valid medical certificate. The instructor's licence was endorsed with a Grade 3 instructor rating. The student pilot held a student pilot licence. ANALYSIS The investigation could not determine the reason for the engine failure, although the circumstances were consistent with fuel starvation. The aircraft departed Canberra with 40 L of useable fuel. The instructor and student had planned for a fuel consumption of 22 L/h, consistent with operations at 75% power and equating to an endurance of 1.8 hours flight time. However, much of the lesson would have required using full power with a fuel consumption rate of about 33 L/h. The aircraft had been operating for 1.2 hours when the engine lost power. It is possible that training manoeuvres resulted in fuel transferring from the left to the right tank, and may explain the fuel quantity imbalance noted during the post-accident examination of the fuel system. While the aircraft may have had sufficient fuel to complete the flight, an uncoordinated turn to position the aircraft for the correct approach may have resulted in the remaining fuel in the right fuel tank being displaced away from the fuel pick-up pipe, disrupting the fuel supply to the engine.

Safety action

As a result of the investigation, the helicopter manufacturer advised that they would examine all bearings on aircraft and assemblies returned for maintenance. The manufacturer advised that a review of the returned assemblies indicated that the change in seal assembly methods introduced in February 1999 appeared to have improved service reliability.

In addition, as a result of reports of failed lower actuator bearings due to insufficient lubrication, the manufacturer issued Service Bulletin SB-42 on 01 August 2001. SB-42 requires lubrication of the lower actuator bearing every 300 flight hours or annually and calls for initial compliance for R44s S/N 0640 and prior by 31 October 2001 (VH-STO was S/N 0369).

Local Safety Action

After consultation with the ATSB, the operator developed and instigated a new inspection and monitoring procedure TSI-146-24-004. This includes the fitment of heat sensitive decals to the RCCB contactor chambers and recording of the observed operating temperatures into a database at regular intervals. This is then used to monitor for any upward trends in operating temperatures of the RCCB.