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Safety Action


The ATSB is undertaking a special study into accidents and incidents resulting from fuel exhaustion and/or starvation. The study is based on accidents resulting from fuel starvation and fuel exhaustion, primarily between 1991 and 2000, but will also consider data back to 1981. The aims of the study are:

  1. to consider accident rates by operation type from 1981 to 2000, and to identify high risk areas;
  2. to identify significant factors underlying the accidents and to compare them with factors identified in earlier research; and
  3. to develop recommendations to reduce the risk and severity of accidents.

The research is expected to be completed and a report published in the second half of 2002.

In relation to the sleep inertia aspects of the investigation, ATSB issued the following Safety Advisory Notices on 15 April 2002:

SAN 20010244

The Australian Transport Safety Bureau alerts all operators in the transport industry, particularly those involved in extended-hours operations, to the possibility of crew members suffering sleep inertia and suggests that operators take steps to mitigate the effects of sleep inertia. The steps should not include subjecting employees to sleep deprivation.

SAN 200100245

The Australian Transport Safety Bureau suggests that the Civil Aviation Safety Authority alert all aviation industry operators to the possibility of sleep inertia impairing performance, particularly that of flight and maintenance crews.

SAN 20020035

The Australian Transport Safety Bureau suggests that the Civil Aviation Safety Authority ensure that operators have strategies in place to mitigate the effects of sleep inertia as part of their fatigue management systems.

The occurrence is one of several that the ATSB believes indicate possible safety deficiencies in aerial work operations, in particular, classification of certain types of passenger-carrying operations. As a result of the ongoing investigation into occurence BO/200100348 near Newman, WA on 26 January 2001, the ATSB issued the following recommendation on 7 September 2001:


The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority consider proposing an increase in the operator's classification, and/or the minimum safety standards required, for organisations that transport their own employees and similar personnel (for example contractors, personnel from related organisations, or prisoners, but not fare-paying passengers) on a regular basis. This recommendation applies to all such operations, regardless of the take-off weight of the aircraft involved.

On 1 February 2002, the Civil Aviation Safety Authority (CASA) provided the following response:

"As you are aware, CASA is presently reviewing the standards contained within the existing Civil Aviation Regulations (CARs) and Civil Aviation Orders (CAOs) with regard to the classification of operations. The input and recommendations contained within the Air Safety Recommendation R20010195 will be taken into consideration and addressed as part of this Project.

"The outcome of the review will determine which category employees (and similar personnel such as contractors) are placed and the standards that will apply to their transportation in aircraft."

The ATSB has classified this response as Monitor pending the outcome of the CASA review.

Any safety output resulting from the investigation into occurence BO/200100348 will be published on the ATSB website www.atsb.gov.au.

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