ATSB research reveals that accidents and incidents are not always reported to the ATSB when they should be. When something goes wrong in transport safety, it is the duty of a ‘responsible person’ (defined in the Transport Safety Investigation Regulations 2003) to report it to the ATSB.
As the national transport safety investigator, the ATSB is the Australian Government agency you should notify in the event of an accident or incident.
While we use your notification to determine whether to investigate an occurrence, looked at as a whole, notifications also give us a bigger picture of aviation safety trends and patterns.
Like a jigsaw piece in a bigger puzzle, certain notifications can often be joined together to reveal a broader, systemic safety problem. Once we've identified an accident or incident trend from your notifications, we can make tangible improvements to safety through safety advisory notices, recommendations and further safety investigations.
Besides the obvious safety benefits of reporting an occurrence, there are also legal requirements to report certain accidents and incidents to the ATSB. Even if there are no injuries or there is minimal aircraft damage, you must still let the ATSB know. Remember that the ATSB does not investigate to lay blame or apportion liability—we investigate to improve safety and prevent an accident from happening again.
You can report an accident or serious incident (an Immediately Reportable Matter — IRM) to the ATSB 24 hours a day, seven days a week:
call 1800 011 034 (you can also use this number if you need advice or clarification on reporting matters)
The ATSB has investigated several accidents that have occurred when maintenance work was being carried out on or near railway tracks. Conducting work on or near a railway track can be dangerous if safeworking rules and procedures have not been correctly implemented to protect the worksite. Trains cannot stop quickly and any breakdown in the communication or management of a worksite can leave workers extremely vulnerable to dangerous situations.
What can you do?
Operational safe working on track requires a high level of preparation and organisation. Whenever there is work taking place on or near a track, coordination and communication are essential. Before authority is granted to occupy or work near a track, it is essential that all information is clearly communicated and verified between the Protection Officer and the Network Control Officer.
An adequate briefing about the work site and effective communications equipment must be made available to the track workers. For track workers, it is vital to ensure that all levels of worksite protection have been fully implemented before commencing work on or near the track.
More information
The following ATSB investigations into accidents involving work on railway tracks, shows the importance of good work practices, coordination and communication:
It is difficult for pilots to spot another aircraft through visual observation alone.
The ATSB often receives reports from pilots that another aircraft is flying too close to them in uncontrolled airspace. Not surprisingly, three quarters of these reports involve pilots flying within 10 nautical miles (18.5 kilometres) of a non-controlled aerodrome.
Twice as many near-collisions are reported to the ATSB where pilots had no prior warning of other aircraft in their vicinity, compared with situations when a pilot received an alert by radio or a traffic alerting system like TCAS.
Insufficient communication between pilots operating in the same area is the most common cause of safety incidents near non-controlled aerodromes.
Get a radio, and always make sufficient broadcasts so that other pilots know your intentions – even when you think there is no nearby traffic.This will increase your chance of detecting other aircraft before it's too late. Making at least the minimum radio broadcasts and using good radio practice alerts other pilots to nearby aircraft and help to reduce the risk of a mid-air collision or a near miss.
Maintain a lookout for other aircraft at all times. There may be a variety of aircraft of different sizes and performance levels all operating at the same time in the same airspace, and some aircraft may not have a radio that is working or is tuned to the correct frequency. Do not rely solely on monitoring your radio to achieve traffic awareness.
Achieve radio alerted see-and-avoid by making all the recommended broadcasts within 10 nautical miles of a non-towered aerodrome. A search for other traffic is eight times more effective when a radio is used in combination with a visual lookout than when no radio is used.
Use the same procedures at all non-towered aerodromes, unless otherwise stated in the En Route Supplement Australia. Following known, standard traffic procedures helps pilots to anticipate the likely position of other aircraft.
Be aware that any radio-equipped aircraft could be conducting base leg entry or straight-in approaches at non-towered aerodromes. Large commercial jet aircraft landing at non-towered aerodromes often make straight-in approaches, but any VHF radio-equipped aircraft are allowed to make these types of approaches.
Avoid overflying aerodromes where possible, and take note of instrument flight rules inbound and outbound routes. Aircraft traffic is relatively dense near aerodromes, particularly on the final approach path to an active runway and on the runway itself.
R44 helicopters with all-aluminium fuel tanks have proven susceptible to post-accident fuel leaks increasing the risk of a potentially fatal post-impact fire following a collision with terrain.
What can you do?
The manufacturer has issued a Service Bulletin SB-78B(Opens in a new tab/window) requiring R44 helicopters with all-aluminium fuel tanks be retrofitted with bladder-type tanks as soon as practical, but no later than 30 April 2013.
The ATSB urges all operators and owners of R44 helicopters fitted with all-aluminium fuel tanks to replace these tanks with bladder-type fuel tanks as detailed in the manufacturer's Service Bulletin 78B as soon as possible.
The fitment of bladder-type fuel tanks to R44 helicopters is a very important safety enhancement that could save lives. The ATSB has also suggested that regulators and investigation agencies in other countries consider what steps they can take to increase compliance with the manufacturer’s safety bulletin.
More information
The ATSB issued a Safety Advisory Notice on 9 March 2012, advising of the potential dangers of the all-aluminum fuel tank.
As part of its preliminary report release on a fatal R44 accident at Bulli Tops in NSW, the ATSB issued a Safety Recommendation to the Civil Aviation Safety Authority (CASA) on 5 April 2013. The ATSB recommended CASA take further action to ensure R44 helicopter operators are aware of regulatory requirements for retrofitting the fuel tank with the bladder-type tank.
In response CASA issued an Airworthiness Bulletin(Opens in a new tab/window) to ensure that all owners, operators and maintainers are aware of the requirements to comply with the manufacturer’s service bulletins.
The ATSB also highlights Service Bulletin SB-82(Opens in a new tab/window) that aims to reduce the chance that the rotor brake switch will act as a possible ignition source in the event of a fuel leak.
Three fatal helicopter accidents also illustrate the potential danger:
Navigation through confined waters under pilotage is a high-pressure situation where errors can easily lead to serious incidents.
What can you do?
The clear and open exchange of information between the ship’s master and crew and the pilot is vital, both during the pilotage passage and before it even commences. This helps to ensure that all members of the bridge team have a shared mental model of the pilotage passage and, as a result, a good understanding of how it should proceed.
This pre-passage information exchange should always include:
the courses or tracks to be followed
speeds at critical points during the pilotage
limits in relation to planned tracks and speeds.
It should also include information on the ship’s handling characteristics and the state of critical equipment such as navigation systems, steering gear, main engine and bow thrusters.
Clear communication is also essential during the passage itself. This is to ensure that the members of the navigation team—including the pilot, bridge team and engineers on duty in the engine room—understand their roles and responsibilities and that instructions are fully understood and correctly actioned. Every member of the team must be free to speak up or “challenge” if they notice something abnormal or they feel that something is amiss.
In addition, a pilotage situation represents a complex environment. This complexity, combined with long hours and the need for precision, can cause fatigue. Precautions must be taken to prevent errors. Especially useful is a fatigue management plan that predicts potential fatigue levels at key positions in the pilotage task and that allows for strategic preparation.
The ATSB has investigated several incidents involving unsafe working practices in the maritime industry. These incidents resulted in serious injury or death following falls from height, crushing and equipment that exploded.
The most common problem associated with these incidents was the fact that the people involved in the task did not properly identify the risks involved before they started the task. Sometimes risk strategies were not implemented, and in some cases, individuals ignored established procedures. To some degree, these incidents involved the people being complacent about the task and this complacency was the direct cause of the injury or fatality.
For most tasks, a comprehensive risk control plan is vital. Ensure that you follow a plan and the established procedures for any task that has risk. Make certain that you know how to do the tasks that have been assigned to you and if you are uncertain about the procedures, talk to your supervisor about your concerns. Remember, safe work procedures are ‘good’ rules to follow and are there to make your workplace safer.
Take the time to evaluate the task you are about to do. Take the time to think about the risks, and what you’re going to do to manage them.
More information
The following ATSB safety investigations show and examine the risks of unsafe working practices, and provide important safety messages for maritime workers and operators, both ashore and at sea:
An increasing trend has been identified where pilots mishandle or mismanage their aircraft and flight profile when unexpected events arise during the approach to land. When compared to other phases of flight, the approach and landing has a substantially increased workload. Pilots and crew must continuously monitor aircraft and approach parameters, and the external environment to ensure they maintain a stable approach profile and make appropriate decisions for a safe landing.
Unexpected developments, or any confusion about roles or procedures can contribute to decisions and actions that increase the safety risk to the aircraft and its passengers.
Standard operating procedures ensure consistency of crew interaction and aircraft operation during an approach and landing.
Make sure you are familiar with the procedures for the approach well ahead of time. If you have any concerns or observe any deviations from the briefed approach, communicate this to the other flight crew without hesitation.
Good communication is vital. If there is any confusion or uncertainty, clarify the situation and take timely action to rectify any deviations before they become a problem.
If there is any doubt about the safety of the aircraft, conducting a go-around is a perfectly legitimate option. Safety trumps scheduling or dignity.
More information
A number of occurrences during the approach to land have been investigated by the ATSB:
General aviation pilots continue to die in accidents that are mostly avoidable. The key hazards that the ATSB has found which increase the risk of an accident are:
flying lower than necessary
experiencing reduced visibility
not being aware that the engine fuel supply is not working
not recognising the implications of something going wrong.
It is necessary to fly low for take-off and landing. The low-flying risks are managed by using circuit patterns at aerodromes, with any obstacles known, so that there is less chance of colliding with other aircraft or unexpected terrain.
Low flying at other times is risky because of the chance of colliding with terrain, or things on the terrain. Collisions happen when pilots cannot see obstacles, do not see obstacles in time to avoid them, or are aware of obstacles but become distracted by another task and fail to avoid the obstacles. Wires are the most common type of obstacles, and pilots collide with them for all of the reasons described above. Low flying also further adds risk because if something does go wrong there is less time or opportunity to fix what has gone wrong.
Reduced visibility
At flying speed, sufficient visibility is needed to allow pilots to see and to avoid obstacles. Visibility is also required to maintain orientation, so pilots know which way is up and can maintain control (the exception is when an aircraft is being controlled using instrument flight techniques). Visibility is reduced by cloud, dark, or materials in the air such as rain, smoke or general haze. Two main risks are associated with flying in limited visibility:
loss of orientation, leading to loss of control of an aircraft and an uncontrolled flight into terrain
insufficient visibility to enable a pilot to see and avoid obstacles while remaining under control, known as a controlled flight into terrain.
The same hazards can also apply during night flight because less can be seen, even though the visibility may be just as good.
Fuel management
There are many ways for the engine fuel supply to be interrupted. The supply may run out because of not knowing the actual amount of fuel on board, or the rate of fuel consumption. The fuel supply may be switched off, particularly in aircraft with more complex fuel systems. The fuel supply may also be stopped by a filter blockage, water in the fuel tank, or a blocked fuel tank vent system. Thorough use of procedures is required to manage the various risks. Hazards increase when a flight is planned to use all the available flight fuel, particularly when the pilot is unfamiliar with the necessary procedures because shorter, non-fuel-critical flights are normally flown.
Management of common threats and errors
Operational problems can develop gradually, like deteriorating weather conditions or increased fuel consumption. Problems can also be sudden, like an unexpected power reduction or an obstacle looming in front of an aircraft in flight. A range of procedures and requirements exist to enable pilots to manage the hazards associated with all the common avoidable accident types.
More information
The ATSB’s Avoidable Accidents booklets feature case studies on regularly occurring accidents that could have been prevented with good flight management and preparation. The booklets also provide helpful hints and strategies to help pilots stay safe when flying.
SafetyWatch is a set of broad safety concerns for the ATSB that have arisen from our investigation findings and from occurrence data reported to us by industry.
These priorities highlight safety issues more broadly with the aim of raise heightened awareness from industry and public, and to help guide ATSB decision-making on investigations.
New confidential reporting regulations and the International Casualty Investigation Code
The ATSB is inviting comments on two proposed regulatory changes relating to:
Confidential reporting of maritime safety concerns
ATSB use of the International Maritime Organization's Casualty Investigation Code
Your comments are sought by Friday, 27 July 2012.
Confidential Reporting (REPCON)
New regulations will replace the existing maritime REPCON regulations creating a multi-modal confidential reporting scheme for the maritime, aviation and rail industries. A multi-modal scheme has the major benefit of allowing all three industries to learn from reports of safety concerns that contain transferable lessons.
Why we need mandatory and confidential reporting
Confidential reporting complements the mandatory reporting system managed by the Australian Maritime Safety Authority. The information we get from both schemes helps us determine whether we need to investigate a safety concern, conduct research and identify trends of emerging hazards and risks. This gives us valuable insight into what needs to be done to improve the safety system. Ultimately, a report now can save lives and prevent injuries in the future.
The Casualty Investigation Code
The IMO's Casualty Investigation Code commenced in January 2010. The Code promotes high and consistent standards for maritime investigations around the world. While the ATSB already acts consistently with the Code, a regulatory amendment is proposed to formalise the ATSB's adherence to the Code.
Providing feedback
Links to the documents below provide further information about the proposed changes.
Consultation Paper
For a full overview of the proposed changes go to:
Enhanced Maritime Confidential Reporting and the Casualty Investigation Code
Reporting and Notifications Australian Transport Safety Bureau PO Box 967 Civic Square ACT 2608
If you have any questions or would like a hard copy of the consultation package, please call the manager of notifications and confidential reporting 1800 011 034.
