Flying at night in remote areas without sufficient visual cues continues to be one of the most dangerous forms of flying, as evidenced by a recent fatal accident in Western Australia’s Kimberley region.

An ATSB investigation into the accident found the pilot of an R22 helicopter, who did not hold a night visual flight rules (VFR) rating or instrument rating, continued flying after last light to try to reach Springvale station.

The lack of local ground lighting on a moonless night meant the pilot had no visual cues to know exactly where the   helicopter was going or reliably control its attitude, and collided with terrain 46km short of the intended destination.

Night flying continues to pose a high risk for many pilots, particularly those in remote areas where there is little to no ground lighting. On average there are two accidents a year that occur from visual flight at night.

“We continue to be concerned about the frequency of accidents – many fatal – that involve pilots flying with reduced visual cues,” said ATSB Chief Commissioner Martin Dolan.

“Based on research from other countries, accidents at night tend to be unforgiving and more likely to lead to death.”

In the 20 years between 1993 and 2012 there were 26 accidents in Australia that occurred in visual (night) conditions. There were also another 10 accidents involving inadvertent VFR flight into 'instrument meteorological conditions', such as poor weather or cloud. Those 36 accidents resulted in 58 deaths. Nearly all of the accidents occurred on dark nights.

“This fatal accident in the Kimberley highlights the inherent high risk of night flying in remote areas,” Mr Dolan said.

For pilots, the ATSB’s message is simple.

“Day VFR pilots need to plan to arrive at their destination at least 10 minutes before last light and to have a realistic ‘Plan B’ to use when it becomes apparent that an intended flight cannot be completed in daylight,” Mr Dolan said.

“It is important, also, for operators and others involved in the operation of aircraft to actively support safety-first pilot decision-making.”

An important safety message

Flying with reduced visual cues is one of the ATSB’s nine SafetyWatch priorities.

Under visual flight rules (VFR), it is crucial pilots have sufficient visual reference to see and avoid obstacles. Visual cues are also required to maintain orientation so VFR pilots know which way is up and can maintain control of their aircraft. There are often less visual cues at night, even though visibility may be good.

More information on flying with reduced visual cues can be found at: www.atsb.gov.au/safetywatch

Read the ATSB investigation report AO-2014-144

ATSB begins action on Canadian review

The ATSB has today begun action in responding to the Transportation Safety Board of Canada (TSB) review into the ATSB’s methodologies and processes.

Released last week, the review found that the ATSB’s investigation methodologies and practices generally met or exceeded international best-practice standards.

The review also highlighted potential improvements, particularly about the way in which ATSB methodologies were applied in the investigation into the ditching of the Pel-Air Westwind Aircraft off Norfolk Island in November 2009.

In response to the TSB review, the ATSB Commission has decided to reopen its investigation into the Pel-Air accident. A new investigation team will review the original investigation and associated report in the light of any fresh evidence and relevant points raised in the TSB review and other recent aviation reviews.

At the same time, the ATSB Commission will continue to methodically and carefully work its way through the broader findings and recommendations of the TSB review, with the aim of ongoing improvements to the future work of the ATSB.

The ATSB will provide regular public updates on the progress with the re-opened Pel-Air review and with its broader consideration of, and response to, the TSB review.

Transport safety investigators from the Asia Pacific region have converged on Canberra this week to learn about how human factors influence accidents.

The 32 participants from five nations will attend lectures and participate in exercises conducted by the Australian Transport Safety Bureau and featuring leading experts in the science.

Course convenor Dr Richard Batt, the ATSB’s Director International, said human factors were a predominant factor in accidents.

“Research shows 80 to 90 per cent of accidents have a human factor involved,” Dr Batt said.

“This can range from things like operator fatigue, stress, workload, or a lack of crew coordination. These are things that affect performance. Human factors is the second part of the accident enquiry. The ‘what happened’ is the technical aspect, while we look at the ‘why factor’.

Regarded as a science in its own right, human factors is used by all major transport nations in accident investigations.

As part of its regional engagement, the ATSB  makes the course available to countries that  are developing a capacity to investigate human factors, or those that want to update their knowledge base.

The overseas nations represented include Taiwan, Cambodia, Malaysia and New Zealand. The course has also attracted accident investigation managers from several Australian airlines (Virgin, QANTAS, Tiger), the Royal Australian Navy, Royal Australian Air Force, Careflight, Melbourne Airport, Queensland Rail and the University of South Australia.

The ATSB, which investigates major aviation, marine and rail accidents, has three human factors investigators in its team, and gives all of its investigators basic human factors awareness training.

From humble beginnings in 1983, the ATSB’s expertise in human factors is recognised around the world. So popular is the course that bookings are already being taken for 2016.

“The ATSB is a centre of excellence in applying technical analysis and human factors to accident investigation and safety,” Dr Batt said. "These are two fundamental strands to a comprehensive transport safety investigation."

“Some of the techniques identified in human factors in transport safety filter through to other industries,” said Dr Batt. “What began as crew resource management in aviation is now applied as team resource management in other sectors.”

MEDIA OPPORTUNITY

• Graduation of course participants
• ATSB Chief Commissioner Martin Dolan, course convenor Dr Richard Batt and participants available for interview
• Friday 21 November, 12.15pm, Crowne Plaza, 1 Binara Street, CANBERRA  ACT

Australia’s transport industries are some of the safest in the world but more can be done to improve safety, according to the ATSB’s annual report.

Approved for tabling by the Deputy Prime Minister the Hon Warren Truss, the annual report highlights the ATSB’s top transport safety concerns across the aviation, maritime and rail industries.

ATSB Chief Commissioner Martin Dolan said the safety concerns bring together the ATSB’s investigation findings and analysis of the safety occurrence data reported by industry.

“We are urging industry to give heightened attention to the risk areas identified by the ATSB,” Mr Dolan said. “While we are seeing improvements in certain areas of transport safety, other risk areas remain a concern to the ATSB. We’ll continue to closely monitor these transport safety hotspots over the coming year.”

One of the year’s notable transport safety achievements was the nation-wide fit out of the bladder-type fuel tank on all Robinson R44 helicopters (in accordance with the manufacturer’s directive). The bladder tank replaced the rigid aluminium fuel tank that was highly susceptible to post-impact fires. 

The ATSB’s growing concern about accidents caused by flying with reduced visual references, such as in cloud or at night, has led to that matter being included as a top transport safety risk area identified in the ATSB’s safety priorities.

“We’ve moved to address concerns about the increasing number of accidents caused by flying with reduced visual references,” Mr Dolan said. “By highlighting these priorities to visual flight rules pilots, we aim to make them more aware of the risks and of what can be done to avoid what can be catastrophic mistakes while flying.”

Three significant investigations into flying with reduced visual cues are included in the annual report, along with features on some of the 217 investigations conducted by the ATSB in 2013–14.

The annual report also details the ATSB’s involvement as the lead organisation in the search for missing Malaysia Airlines flight MH370 that disappeared in March 2014. “Finding the missing aircraft and helping solve the mystery of its disappearance is our greatest challenge. Just as importantly, though, we continue our work to improve safety through investigating aviation, maritime and rail incidents at home,” Mr Dolan said.

Australia’s current top transport safety priorities across aviation, maritime and rail (SafetyWatch):

1. Flying with reduced visual cues
2. Marine work practices
3. Safe work on rail
4. Data input areas for aviation
5. Safety around non-controlled aerodromes
6. General aviation pilot risks
7. Maritime pilotage
8. Under reporting of occurrences
9. Handling approach to land

More information on these risk areas can be found at the ATSB’s SafetyWatch web page www.atsb.gov.au/safetywatch

Download: ATSB Annual report 2013-14

The ATSB will today conduct an onsite media briefing on its investigation into the 14 October 2014 aircraft accident of a Van’s RV-6A, at Chelsea, Melbourne, Victoria.

The Investigator-in-Charge will discuss factual information known to the ATSB at this time and will outline the investigation process.

The ATSB has deployed three investigators, who have already begun work at the accident site. Over the next few days they will examine the wreckage site, interview witnesses and collect maintenance records.

The investigators are seeking witness reports as well as video or imagery that might assist the investigation. Witnesses can call the ATSB on 1800 020 616.

Where: Camp Street, Chelsea, Vic.

When: 1:00 PM AEDT, 15 October 2014

The ATSB is urging pilots of single-engine aircraft to plan for partial power loss, following the release of a new educational video.

Between 2000 and 2010, there were nine fatal accidents resulting in 20 people losing their lives as a result of a response to a partial power loss soon after take-off. Importantly, there were no fatal accidents where the engine initially completely failed.

ATSB research manager Dr Stuart Godley says the high number of fatalities and serious injuries resulting from partial power loss should be of concern to pilots and flight instructors.

“Historically, the simulated total loss of power and subsequent practice forced landing has been the core of a pilot’s emergency training,” Dr Godley says. “However, our accident data shows that for single engine aircraft, a partial power loss during and after take-off is three times more likely to occur than a complete engine failure.”

While partial power loss can be more challenging to manage—due to the number of choices and decisions confronting the pilot—Dr Godley says that the lack of training, coupled with the lack of pilot preparation and planning, may also help explain the higher number of fatalities.

“Total engine failure after take-off is part of the Day VFR syllabus and is taught and practiced throughout a pilot’s initial training. However, partial power loss after take-off is not a practiced syllabus item and probably does not receive the same emphasis during training.

“A pre-flight briefing for both a complete engine failure and partial power loss is the key to a pilot maintaining control of their aircraft.” says Dr Godley.

The new short video, available on the ATSB’s YouTube channe(Opens in a new tab/window)l (ATSBinfo) provides pilots and flight instructors advice on how to manage the dangers surrounding partial power loss in single engine aircraft.

More information about managing partial power loss in single-engine aircraft is also available in the ATSB’s avoidable accident booklet, Managing partial power loss after take-off in single-engine aircraft.

The ATSB today released a request for tender to acquire the services of a specialist company capable of conducting a deep-water search under ATSB direction for missing Malaysia Airlines Flight MH370.

Engaged as a prime contractor, the company will provide the expertise, equipment and vessel(s) necessary to undertake an intensified underwater search for the missing Boeing 777 aircraft in the defined zone in the southern Indian Ocean.

While the precise search zone is currently being established by an international search strategy working group, it is expected that the successful tenderer will search an area up to 60,000 square kilometres based on the 'seventh handshake' arc where the aircraft last communicated with the Inmarsat satellite. Definition of the search zone will be finalised within two to three weeks.

The successful tenderer will localise, positively identify and map the debris field of MH370 using specialist equipment such as towed and autonomous underwater vehicles with mounted sonar and/or optical imaging systems.

The intensified search will begin in August 2014 and is expected to take up to 12 months, depending on weather conditions. The successful tenderer will use the data from a bathymetric survey (already underway) to navigate the search zone, which has water depth between 1000 and 6000 metres.

The search vessel(s) used by the prime contractor may also be coordinated with other vessels also undertaking search activities in the search zone on behalf of other countries.

A copy of the request for tender is available on the AusTender website at www.tenders.gov.au(Opens in a new tab/window). Request for tender submissions are due by 5.30pm AEST on 30 June 2014. 

At the request of the Malaysian Government, the ATSB is leading the search for missing Malaysia Airlines Flight MH370.

All enquiries relating to the tender: opsearch@atsb.gov.au

Onsite media briefing:

The ATSB will conduct an onsite media briefing on its investigation into the 20 July 2014 aircraft accident near Burrumbuttock, NSW.

The Investigator-in-Charge will discuss factual information known to the ATSB at this time and will outline the investigation process.

The ATSB has deployed two investigators, who have already begun work at the accident site. Over the next few days they will examine the circumstances around the accident and gather information from the wreckage site, witnesses and aircraft maintenance records.

The investigators are seeking witness reports that might assist the investigation. Witnesses can call the ATSB on 1800 020 616.

Where: Urana Road, Burrumbuttock, NSW

When: 3:30 PM EST, 21 July 2014

In response to a request from the Ukrainian authorities, the Australian Transport Safety Bureau is deploying two of its investigators to Kiev to support an international investigation into the events surrounding the tragic crash of Malaysia Airlines flight MH17.

The investigators, with backgrounds in aircraft operations and aeronautical engineering, will form part of a concerted international effort to determine the cause of the crash of MH17.

The investigators are expected to arrive in Kiev on Tuesday 22 July.

The Australian Transport Safety Bureau (ATSB) is satisfied that the unidentified material found 10 kilometres east of Augusta, Western Australia is not associated with missing Malaysia Airlines flight MH370.

This assessment follows the ATSB's careful examination of a set of forensic photographs supplied by the West Australian Police yesterday.

ATSB Chief Commissioner, Mr Martin Dolan, said the ATSB takes all suspected leads in the search for the missing aircraft very seriously.

"The ATSB examined the forensic photographs of the material to see if it has any relevance to the search of MH370," Mr Dolan said.

"After careful and detailed examination by investigative experts, our assessment is that the material is highly unlikely to be related to MH370 and will not be used in the search for the missing aircraft.

"We also passed the photographs to the Malaysian authorities, who are leading the investigation."