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Australian Transport Safety Bureau (ATSB)

Beechcraft B200 King Air aircraft, registered VH-ZCR

The importance of following a cockpit checklist

The investigation into the accident of a King Air at Essendon Airport highlights the importance of using a checklist.

Don't push it, Land it

Don't push it, LAND IT

Make an early decision to land your helicopter during the onset of an abnormal situation.

Aviation Safety Digest

The 'Crash Comic' now online

Over 150 editions of the iconic Aviation Safety Digest are now available online.

Virgin Australia Boeing 737

Objectivity can reduce risk

Objective interpretation of runway surface conditions can reduce risk.

Cessna C208 registered VH-SJJ

See-and-avoid is a must

Effective see-and-avoid methods avoid traffic conflicts at non-ATC controlled airports.

Bulk carrier, Aquadiva

Understand the plan

Shared understanding of passage plan needed for safe voyage

Pitot probe covers the focus of safety advisory notice for operators at Brisbane Airport

The ATSB has issued a safety advisory notice to all operators flying to Brisbane Airport.

Signature signing

ASAM to help improve safety

The Australasian Society of Aerospace Medicine and ATSB have signed an MoU to improve safety.

On track to greater insights

The ATSB has gained access to a new data feed of rail safety occurrences to help improve safety on our tracks.

ATSB supports Rail Safety Week 2018

This year’s Rail Safety Week is a timely reminder for drivers of the hazards around crossing level crossings.

Dr Rob Lee AO inducted into the Aviation Hall of Fame

Aviation Hall of Fame

The ATSB welcomes the announcement of the induction of aviation safety visionary Dr Rob Lee AO into the Australian Aviation Hall of Fame (AAHOF).

Saxon Onward, alongside in Eden

Avoiding action must be early and effective

The vessels had been aware of each other’s presence well before the collision took place.

Check your checklist

The investigation into the accident of a King Air at Essendon Airport highlights the importance of using a checklist.

Don't push it, LAND IT

Make an early decision to land your helicopter during the onset of an abnormal situation.

Aviation Safety Digest online

Over 150 editions of the iconic Aviation Safety Digest are now available online.

Objectivity can reduce risk

Objective interpretation of runway surface conditions can reduce risk.

See-and-avoid is a must

Effective see-and-avoid methods avoid traffic conflicts at non-ATC controlled airports.

Understand the plan

Shared understanding of passage plan needed for safe voyage

Pitot probe investigation

The ATSB has issued a safety advisory notice to all operators flying to Brisbane Airport.

ASAM to help improve safety

The Australasian Society of Aerospace Medicine and ATSB have signed an MoU to improve safety.

New rail data improves safety

The ATSB has gained access to a new data feed of rail safety occurrences to help improve safety on our tracks.

Supporting Rail Safety Week

This year’s Rail Safety Week is a timely reminder for drivers of the hazards around crossing level crossings.

Aviation Hall of Fame

The ATSB welcomes the announcement of the induction of aviation safety visionary Dr Rob Lee AO into the Australian Aviation Hall of Fame (AAHOF).

Collision at sea

The vessels had been aware of each other’s presence well before the collision took place.

Awarding safety contribution

Outgoing Director of Defence Aviation and Air Force Safety awarded for his contribution to improving aviation safety.

View all news items

Don't push it, LAND IT

Don't push it, LAND IT

Make an early decision to land your helicopter during the onset of an abnormal situation. Read more on "Don't push it, LAND IT"

- Loss of control and collision with terrain involving B200 King Air, VH-ZCR at Essendon Airport, Victoria on 21 February 2017
  - final report release
  The ATSB found that the pilot did not detect that the aircraft’s rudder trim was in the full nose-left position prior to take-off. The position of the rudder trim resulted in a loss of directional control and had a significant impact on the aircraft’s climb performance in the latter part of the flight.
- Derailment of freight train in Devonport, Tasmania on 21 September 2018
  - new active investigation
  The ATSB is investigating the derailment of a freight train in Devonport, Tasmania. At approximately 0900 on 21 September 2018, a freight train operated by TasRail was being loaded with cement, the train departed without any command from the remote driver.
- Reduced braking effectiveness during landing involving Boeing 737-800, VH-VOP, Christchurch New Zealand, on 11 May 2015
  - final report release
  The ATSB’s final report into the reduced braking effectiveness during the landing of a Boeing 737 at Christchurch International Airport in May 2015 highlights the need for objective methods to interpret runway surface conditions.
- Level crossing collision between freight train 8279 and a truck, at level crossing 5318, near Yalboroo, Queensland, on 29 August 2017
  - final report release
  The investigation into the fatal collision between a freight train and a truck highlights the risks that exist at private rail crossings.
- Safeworking irregularity near Flemington, NSW, on 3 September 2018
  - new active investigation
  The ATSB is investigating a safeworking irregularity near Flemington, NSW, on 3 September 2018.
- Near grounding of Aquadiva, Newcastle Harbour, NSW, on 12 February 2017
  - final report release
  The ATSB’s final report into the near grounding of Aquadiva in Newcastle Harbour highlights the need for harbour pilots and bridge crews to have a shared understanding of a ship’s passage plan to ensure a safe voyage.
- Lay-over landing involving Kavanagh Balloons E-240, VH-DUX, 18 km E of Essendon Airport, Victoria, on 2 April 2018
  - final report release
  The ATSB’s final report into a lay-over landing involving a Kavanagh Balloons E-240 demonstrated how effective communication from the pilot during safety briefings resulted in all passengers adopting in the correct landing position.
- Airspeed indication failure on take-off involving Airbus A330, 9M-MTK, Brisbane Airport, Queensland, on 18 July 2018
  - preliminary report
  A safety advisory notice released today advises operators flying to Brisbane Airport to consider the use of pitot probe covers and ensure rigorous processes are in place to confirm the covers are removed before flight.
- Electrical short circuit and forward cargo compartment smoke event involving Boeing 777-300ER, A6-ETR, 530 km NNW Adelaide, South Australia on 14 October 2017
  - final report release
  Despite complex systems of design and manufacturing, training, and quality control, errors do occur during manufacturing that may not be apparent for some time. In this case, the aircraft was manufactured 4 years prior to the incident.
- In-flight engine malfunction involving Cessna Citation 560, VH-PSU, 296 km north of Brisbane Airport, Queensland, on 26 January 2018
  - final report release
  A loud noise from the rear of the aircraft and the smell of smoke prompted an emergency return to the airport.
- Derailment of train 7MP7 at Coonana, WA on 19 August 2018
  - new active investigation
  The ATSB is investgating the derailment of train 7MP7 at Coonana, Western Australia on 19 August 2018. Two locomotives and three wagons were derailed (including crew van). There was significant track and rolling stock damage.
- Load irregularity involving freight train YC77 at Cooroy, Qld, on 18 August 2018
  - new active investigation
  The ATSB is investigating a load irregularity involving freight train YC77 at Cooroy, Qld, on 18 August 2018.
- Collision with terrain involving BK117 helicopter, VH-JWB, near Ulladulla NSW, on 17 August 2018
  - new active investigation
  Four investigators from Brisbane and Canberra will travel to the accident site to begin the evidence collection phase of the investigation. This will include the examination of the wreckage, interviewing witnesses, and obtaining any available recorded data for analysis, amongst other activities.
- Depressurisation and crew incapacitation involving B737, VH-XMO, near Narrandera NSW, on 15 August 2018
  - new active investigation
  The ATSB is investigating an depressurisation and crew incapacitation involving a B737, VH-XMO, near Narrandera NSW. During cruise, the crew of the cargo flight received a wing body overheat warning resulting in a reduction of cabin pressure. The crew donned oxygen and descended to 20,000 ft. The First Officer was subsequently incapacitated and the Captain descended to 8,000 ft and diverted the aircraft to Canberra.
- Fuel exhaustion and collision with terrain involving McDonnell Douglas Corporation 369, VH-PLY, 36 km NW Hawker, South Australia, on 17 July 2016
  - final report release
  ATSB safety advisory notice released today advises commercial operators of aircraft up to 5,700 kg maximum take-off weight (MTOW) to publish procedures in their operations manuals for pilots to verify fuel quantity before and during flight, to reduce the risk of a fuel exhaustion event
- Loss of containers overboard involving YM Efficiency, off Newcastle, NSW, on 1 June 2018
  - preliminary report
  The ATSB has released the preliminary investigation report into the loss of containers overboard from cargo ship, YM Efficiency.
- Collision between Beijing Bridge and Saxon Onward, off Gabo Island, Victoria, on 23 January 2018
  - final report release
  This accident highlights the importance of keeping a proper lookout and taking early and effective avoiding action.
- Collision with terrain involving Cessna 172S, VH-EWE, near Moorabbin Airport, Victoria, on 8 June 2018
  - preliminary report
  The ATSB has released the preliminary investigation report into the fatal Cessna 172S accident near Moorabbin Airport.
- Operational non-compliance involving Airbus A320, PK-AZE, Perth Airport, Western Australia, on 24 November 2017
  - preliminary report release
  The ATSB released its preliminary investigation report into the operational non-compliance of an Airbus A320 at Perth Airport, in Western Australia, on 24 November 2017. The investigation is continuing.
- Collision with terrain involving Cirrus SR22, VH-PDC, Orange Airport, NSW, on 15 May 2018
  - preliminary report
  The ATSB has released its preliminary investigation report into a collision into terrain involving a Cirrus SR22, at Orange Airport, NSW, on 15 May 2018. The investigation is continuing.
- Engine failure involving Bombardier DHC-8, VH-LQD, near Brisbane, Qld on 26 June 2018
  - new active investigation
  During the cruise, the right engine failed and the crew were unable to feather the propeller. The aircraft continued to Brisbane Airport where the aircraft landed safely.
- Near-collision and operational event involving Beech Aircraft Corp. B200, VH-OWN and Beech Aircraft Corp. B200, VH-LQR, Mount Hotham, Victoria on 3 September 2015
  - final report release
  Maintaining the pilot skill of operating an aircraft without the use of automation is essential in providing redundancy should the available automation be unexpectedly reduced.
- Flight below minimum altitude involving Boeing 777, ZK-OKN, near Brisbane Airport, Queensland, on 18 November 2017
  - final report release
  The ATSB’s investigation report into a flight below minimum altitude involving a Boeing 777, 23 km SSW of Brisbane Airport, demonstrates how errors can create increased workloads during high workload phases of flight and increase the risk of a safety occurrence.

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