The Transportation Safety Board of Canada (TSB) will conduct an independent external review of the ATSB’s investigation processes and publish the results. The review was announced today by TSB Chair, Wendy A. Tadros and ATSB Chief Commissioner, Martin Dolan. 

The review, to begin with an initial visit by the TSB team this month, will provide an independent and objective assessment of the ATSB’s investigation methodology and processes. 

The review team will benchmark TSB investigation methodologies with the ATSB’s and compare them with international standards. The review will also examine how ATSB methodologies and processes have been applied to ATSB investigations and compare them with TSB approaches. 

Mr Dolan said the review is a new step in the ATSB’s continuing close cooperation with other international investigation agencies. It will provide both organisations with a significant learning opportunity.

“I invited the TSB to conduct the review because we are always looking to improve our investigation systems and approaches,” Mr Dolan said. “I’m grateful that our Canadian colleagues have agreed”.

“The review will identify best practices from both organisations that we can adopt to improve how we investigate accidents and occurrences and improve transport safety.

“The TSB is well placed to conduct this review as they have a similar legislative framework to the ATSB and a long-standing commitment to systemic investigation to improve safety.”

It is anticipated that the TSB will produce a final report early in the northern spring of 2014. The report will be published by the TSB and available on the TSB website. 

Any questions about the TSB review should be directed to the ATSB on 1800 020 616.

Today the ATSB released the first in a series of short YouTube videos highlighting areas where more can be done to improve transport safety in Australia. 

The first video focuses on the recurring dangers facing general aviation pilots, particularly around low-level flying, striking power lines, fuel management and flying into bad weather.

ATSB Chief Commissioner, Martin Dolan, said the videos are part of the ATSB’s efforts to increase awareness of the recurrent risks that need to be managed in the aviation, maritime and rail communities. 

“We’re finding through our investigations that many accidents, even fatal ones, are avoidable through better planning and execution,” Mr Dolan said.

“We’ve produced these videos to help the transport industry give heightened attention to these areas of safety concern. 

“The videos contain case studies of accidents and incidents along with advice from the ATSB’s own investigators. They send a powerful message from the people who are in the best position to understand the consequences when things go wrong.”

The ATSB will release eight videos over the coming weeks. The other topics that will feature in the series include safe work on rail, safety around non-towered aerodromes, maritime pilotage, data input errors, handling approach to land, under reporting of occurrences, and marine work practices.  

The videos can be found on the ATSB’s YouTube channel ATSBinfo(Opens in a new tab/window).

More information about these top safety concerns is available on the ATSB’s SafetyWatch page. 

The ATSB today released the final report of its investigation into the uncontained engine failure involving a Qantas Airbus A380 over Batam Island, Indonesia on 4 November 2010. 

The accident occurred shortly after the aircraft took off from Singapore. At about 7,000 ft above Batam Island, one of the aircraft’s Rolls-Royce Trent 900 engines failed, sending debris into the aircraft’s left wing and fuselage, and onto Batam Island. There was significant damage to the aircraft’s electrical, hydraulic and other systems. The crew managed the multitude of system failures before safely returning and landing the aircraft.

The ATSB found that the engine failure was the result of a fatigue crack in an oil feed pipe. The crack allowed the release of oil that resulted in an internal oil fire. The oil fire led to one of the engine’s turbine discs separating from the drive shaft. The disc then over-accelerated and broke apart, bursting through the engine casing and releasing other high energy debris.

The ATSB also found that the oil pipe, together with a number of similar pipes in other engines, had been made with a thin wall section and did not comply with the design specifications. The thin wall substantially increased the likelihood of fatigue cracking.

This investigation has been one of the more complex undertaken by the ATSB in recent years and has involved a large commitment of resources. As well as understanding how the engine failed, the investigation had to review why quality assurance did not adequately manage the oil pipe problem and what were the implications of the damage to the aircraft.

The ATSB worked closely with international regulators, Rolls-Royce and Airbus to ensure the continued safety of Trent 900-powered A380s. Early in the investigation, the ATSB issued a recommendation to Rolls-Royce about the manufacture of the oil feed stub pipes. As part of its final report, the ATSB issued recommendations to the European and US regulators so that lessons learned from this accident would be incorporated into aircraft certification advisory material designed to minimise hazards from uncontained engine failures.

As a result of the ATSB’s investigation, regulatory authorities and operators around the world took steps to ensure that engines with non-conforming oil feed stub pipes were identified and managed appropriately. Rolls-Royce also made changes to their quality assurance system to improve the way they manage non-conforming parts. 

Read the report: In-flight uncontained engine failure Airbus A380-842, VH-OQA, overhead Batam Island, Indonesia, on 4 November 2010

Fact Sheet PDF [ PDF: 767KB]

Fact sheet

The ATSB’s investigation into the uncontained engine failure of a Qantas Airbus A380 over Batam Island, Indonesia on 4 November 2010

What happened and why

Shortly after taking off from Changi Airport, Singapore, the No. 2 engine on a Qantas Airbus A380 failed about 7,000 ft above Batam Island, Indonesia. The failure sent engine fragments through the left wing and damaged some of the aircraft’s systems.

The engine failure was a result of an oil feed stub pipe that was incorrectly manufactured with a thin wall that resulted in fatigue cracking of the pipe. This crack released oil into the engine during the flight, which caused an internal fire. That fire led to one of the engine’s turbine discs fracturing and then rapidly over speeding before it burst, broke free of the engine casing, and impacted the A380’s airframe.

What happened to the aircraft?

The damage to the aircraft from the disc fragments resulted in the aircraft’s hydraulic, electrical and other systems being degraded.

Despite the damage, the flight crew managed the multitude of system failures before safely returning the aircraft and landing at Changi Airport without any injuries to the crew and passengers.

What’s been done to prevent this from happening again?

The ATSB, Rolls-Royce, aviation regulators, and operators of Trent 900-powered A380s took a range of steps to ensure that engines with incorrectly manufactured oil feed stub pipes were removed from service or managed to enable the aircraft to continue to operate safely.

Rolls-Royce also introduced software that would automatically shut down a Trent 900 engine before its turbine disc over speeds, in the unlikely event of a similar occurrence. As well, Rolls-Royce had improved their quality management system and management of non-conforming parts.

Lessons for future safety

The damage to the aircraft’s airframe by the disc fragments highlighted a safety issue with the existing airframe certification standards. The ATSB has issued a safety recommendation to the United States Federal Aviation Administration and the European Aviation Safety Agency to review and incorporate any lessons learned from this accident into their aircraft certification advisory material regarding the minimisation of the hazards from uncontained engine rotor failures.

On Thursday 27 June 2013, the Australian Transport Safety Bureau (ATSB) will hold a media briefing to accompany the release of its final investigation report into the in-flight uncontained engine failure in a Qantas A380 overhead Batam Island, Indonesia on 4 November 2010 (QF32).

ATSB Chief Commissioner Mr Martin Dolan will present the facts, findings and lessons learnt from the investigation. 

Where: 62 Northbourne Avenue, Canberra City, ACT
(ATSB Central Office)

Time: 10:30am (AEST), Thursday 27 June 2013

Copies of the investigation report will be available from 10.30am. An audio recording of the media briefing will be available after midday.

The ATSB is concerned that a significant number of R44 helicopters are at risk of fire after an accident because their fuel tanks have not been retrofitted with a safety improvement. 

In its preliminary investigation report, released today, into last month’s fatal R44 helicopter accident at Bulli Tops in NSW, the ATSB highlights the similarities of this accident with others involving R44 helicopters with all-aluminium fuel tanks.

The Bulli Tops accident occurred on 21 March when an R44 helicopter caught fire after striking a tree and colliding with the ground. The pilot and three passengers died in the accident. The circumstances of this accident are consistent with two recent R44 accidents in Australia where the all-aluminium fuel tank ruptured, resulting in a fuel-fed fire after impact. 

The Robinson Helicopter Company (the R44 manufacturer) had previously issued a service bulletin that requires owners to replace the all-aluminium fuel tank with a bladder-type tank before 30 April 2013. Bladder tanks substantially reduce the risk of a post-impact fire.

Australia’s aviation safety regulator, the Civil Aviation Safety Authority (CASA), confirmed to the ATSB that most owners of R44 helicopters are legally required to replace their fuel tanks before 30 April 2013. Despite this, the ATSB has assessed that about 100 Australian R44 helicopters will not have met the service bulletin by the due date.

The ATSB remains concerned at the significant risk facing many R44 helicopters and has recommended that CASA take further action to ensure compliance with the manufacturer’s service bulletin. CASA subsequently issued an Airworthiness Bulletin reminding registered operators of R44s about their maintenance responsibilities and making it clear that CASA would regard as deficient any system of maintenance that did not include the service bulletin.

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 take note of its preliminary report and consider what steps they can take to increase compliance with the manufacturer’s safety bulletin.

The preliminary investigation report into last month’s R44 helicopter accident at Bulli Tops is available on the ATSB website at www.atsb.gov.au.

The ATSB will conduct an on-site media briefing on its investigation into the 17 March 2013 fatal aircraft accident near Parafield Airport, South Australia.

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

The ATSB has deployed three investigators, with specialisations in engineering and aircraft operations. They have already begun work at the accident site. Over the next few days they will examine the wreckage and accident site, interview witnesses, collect maintenance and pilot records and examine any relevant recorded air traffic control radio and radar data.

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

Where: The gate of RM Williams, Frost Rd, Salisbury, South Australia

When: 1.00 pm (CDT), 18 March 2013

The Australian Transport Safety Bureau (ATSB), at the request of the Queensland Government, has initiated an investigation into the passenger train accident at Cleveland Station in Brisbane yesterday.

The accident occurred when a QR passenger train failed to stop at the Cleveland station platform and collided with the end-of-line buffer-stop, the platform and the station building. There were 15 people on board the train (including the driver and a guard) while four people were on the platform and in the station building. A number of people were treated for minor injuries and transported to hospital for further examination.

The ATSB investigation team will be inspecting the accident site this afternoon and have been liaising with officers from the Queensland Police Service, the Department of Transport and Main Roads and Queensland Rail to gather relevant evidence. Witnesses will be interviewed in the coming days.

The ATSB expect to release a preliminary factual report within a month. More information will be made available as it comes to hand.

ATSB investigation RO-2013-005

The Australian Transport Safety Bureau (ATSB) is Australia's national transport safety investigator.

This week’s tragic aircraft accident of a Cessna 182A at Burrum Heads, Queensland highlights the heightened risk of general aviation pilots flying low, and the hazard posed by powerlines. 

On 17 December, witnesses reported seeing a Cessna 182A hit a powerline before colliding with terrain. The pilot—the only person on board the aircraft—died in the accident. The Australian Transport Safety Bureau (ATSB) completed the on-site phase of its investigation yesterday. While the investigation is still in its early days, preliminary evidence suggests that the aircraft struck a wire while flying at a very low altitude. The low-level flight phase was not part of a landing or take off. 

ATSB General Manager of Aviation Safety Investigations, Mr Ian Sangston, said that low-level flying, especially around powerlines, presents major risks to general aviation pilots. 

‘Unnecessary and unauthorised flying at low altitudes adds an extra level of complexity and danger,’ said Mr Sangston. ‘There are many obstacles to avoid and it creates a much greater risk. That’s why low-level flying requires special training and endorsements, and should never be undertaken without authorisation and a good reason.’

‘This tragedy is a timely reminder for all pilots to consider the dangers of low-level flying and flying around wires.’

The ATSB investigation team is seeking witness reports including any video footage that might assist with the investigation. Witnesses can call the ATSB on 1800 020 616. 

The ATSB’s Avoidable Accident booklet series provides important advice to pilots on low-level flying and wirestrikes. The booklets Wirestrikes involving known wires: A manageable aerial agriculture hazard and Low-level flying can be found on the ATSB website at www.atsb.gov.au

Details of the investigation AO-2012-170 are also available on the ATSB website. 

The ATSB will conduct an onsite media briefing on its investigation into the 17 December 2012 fatal aircraft accident at Burrum Heads, Queensland.

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

The ATSB has deployed four investigators, with specializations in engineering and aircraft operations. They have already begun work at the accident site. Over the coming days they will finalise their examination of the wreckage site and interview witnesses.

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

Where: On the road verge near 805 Burrum Heads Rd, Qld

When: 4:00pm (AEST), 18 December 2012

The ATSB is urging pilots and operators to report wirestrikes and all significant aviation occurrences.

Even if there's no damage to the aircraft or no injuries to people onboard the aircraft, reporting can help identify hotspots and ultimately save lives.

Wirestrikes occur when an aircraft flies into a powerline or cable. They can happen to any low-flying aircraft involved in any operation, including aerial agricultural and mustering, private flights, sport aviation, and survey flights.

A new report released today by the Australian Transport Safety Bureau (ATSB) shows that around 100 wirestrikes had not been reported between 2003 and 2011. Under law, aviation accidents and serious incidents, such as wirestrikes, need to be reported to the ATSB.

ATSB Chief Commissioner Martin Dolan said the reporting of wirestrikes and other aviation occurrences greatly helps in preventing loss of life and injuries.

"We need to be told when things go wrong, so that we can examine what happened and see what needs to be done to improve future safety."

Pilots and operators involved in a wirestrike occurrence should report to the ATSB. Notifications can be made via the toll free number 1800 011 034 (available 24/7) or via the ATSB notification website.

Follow this link for a copy of the report, Under reporting of aviation wirestrikes.