Systemic safety issues in Queensland coastal pilotage operations have been identified in an Australian Transport Safety Bureau (ATSB) investigation report, released today.

Coastal pilots form a key defence against a serious shipping incident in parts of the Great Barrier Reef and Torres Strait as part of a suite of broader protective measures already in place.

The ATSB began an investigation into coastal pilotage operations in December 2010 following the release of its report into the grounding of the piloted tanker Atlantic Blue in the Torres Strait and a request from the Australian Maritime Safety Authority (AMSA)—the coastal pilotage safety regulator. That report identified safety issues affecting coastal pilotage which indicated that other systemic issues may also exist that would benefit from the ATSB further investigating.

The ATSB’s safety issue investigation found that under the coastal pilotage regulations, no organisation, including the pilotage provider companies, has been made clearly responsible and held accountable for managing the safety risks associated with pilotage operations. This has meant that responsibility for managing the most safety critical aspects of pilotage has rested with individual pilot contractors instead of an organisation that systematically manages safety risk.

The investigation also identified systemic safety issues surrounding pilot training, fatigue management, incident reporting, competency assessment and use of coastal vessel traffic services.

AMSA has already taken and proposed safety action to address the issues identified and is working with pilots, pilotage providers and industry to make further improvements to shipping safety in the region. Significant AMSA action includes the publishing of standard passage plans for pilotage, and requiring pilotage providers to develop standard operating procedures for pilotage tasks undertaken by their contractor pilots. On 1 July 2012, AMSA also began a review of its coastal pilotage regulations.

The ATSB welcomes AMSA’s response but considers further action is necessary to fully address the safety issues. In particular, the ATSB is recommending that AMSA ensures that the coastal pilotage regulations specifically assign responsibility for the safe management of pilotage operations to the pilotage providers or another organisation.

The ATSB has also issued recommendations to the three coastal pilotage providers to take safety action in relation to fatigue management and incident reporting to facilitate action by AMSA.

Following the allowed 90-day period after the issue of its recommendations, the ATSB will reassess the safety risk based on the action taken and proposed by AMSA, and the pilotage providers to address the issues.

The report Safety issue investigation into Queensland Coastal Pilotage (MI-2010-011) is available on the ATSB website.

An incident with an overheating mobile phone on board an aircraft highlights the importance of taking precautions with lithium battery-powered devices, especially when travelling, according to the ATSB.

On 25 November 2011, shortly after a Rex Airlines Saab aircraft arrived at Sydney airport, a passenger's Apple iPhone began to overheat and give off smoke in the passenger cabin. A cabin crew member used a fire extinguisher on the phone, and after several minutes, the smoke cleared.

The ATSB investigation found that a small metal screw had been misplaced in the phone's battery bay-probably during earlier repairs. The stray screw punctured the battery casing, causing an internal short circuit that led to heating-heating that increased as the battery reacted and began to break down.

Significantly, the phone repairs had not been conducted by an authorised service provider.

ATSB Chief Commissioner, Mr Martin Dolan, said passengers should be aware of the safety measures needed for flying with lithium battery-powered devices.

"When travelling with mobile phones, laptops and other portable electronic devices-or just their batteries-passengers should, wherever possible, carry them in the cabin, and not in checked-in baggage," Mr Dolan says. "This reinforces the Civil Aviation Safety Authority's recommendations for flying with lithium battery-powered devices."

"The incident also highlights the importance of good maintenance and repair processes for these devices, and the risk of using non-authorised repair agents."

The complete final report is available on the ATSB website.

The Civil Aviation Safety Authority's advice on carrying lithium batteries on aircraft is available on the CASA website, at www.casa.gov.au/dg/(Opens in a new tab/window)

On Thursday 2 February 2012, the Australian Transport Safety Bureau (ATSB) will hold a media briefing to accompany the release of its preliminary investigation report into the 8 January 2012 foundering of the Panamanian registered general cargo ship Tycoon at Christmas Island.

ATSB Chief Commissioner Mr Martin Dolan will present the facts of the accident and outline the direction of the ATSB's ongoing investigation.

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

Time: 11.00am (AEDT), Thursday 2 February 2012

Copies of the investigation report will be available from 11.00am. An audio recording of the media briefing will be available after midday.

In its preliminary investigation report released today, the ATSB describes the events leading to the accident involving the Panama-registered general cargo ship Tycoon on 8 January, and outlines the direction the investigation will be taking.

While Tycoon was moored in Flying Fish Cove at Christmas Island, an increase in wind speed and sea conditions combined with a failure in the ship's mooring so that the ship made contact with the adjacent rock-face and shore crane pylon. Despite attempts by crew to move the ship, it continued to hit against the rock-face and pylon.

A one-metre long hole was torn in the hull. This flooded the engine room and allowed oil and other pollutants to be washed into the sea. The crew subsequently abandoned the ship and were rescued by the Royal Australian Navy.

The following day, the starboard side of Tycoon's hull collapsed inward, exposing the contents of the hold to the sea. The wreck remains alongside the rock-face awaiting salvage.

The ongoing ATSB investigation will now focus on:

• the actions of the Tycoon's master and crew and those of the port's operational staff
• the failure of the port's permanent stern mooring arrangement and the design and maintenance of the mooring system
• port operational procedures, guidelines and risk assessment
• the condition of Tycoon and the adequacy of the ship's mooring equipment
• Tycoon's safety management system and other on board guidance material.

A copy of the preliminary factual report MO-2012-001.

The poor management of fuel in some aircraft operations continues to pose a serious risk to aviation safety according to the Australian Transport Safety Bureau.

ATSB Chief Commissioner, Mr Martin Dolan, said fuel mismanagement is a continuing concern for the ATSB due to the high number of fuel-related occurrences reported each year.

'Each year, the ATSB receives more than 20 reports of fuel exhaustion or starvation incidents and accidents,' Mr Dolan said.

'These events have led to forced landings, diversions to other aerodromes and, in the worst cases, fatal crashes.'

'Many accidents involving fuel exhaustion and starvation are avoidable through good fuel management practices and procedures.'

ATSB data reveals that aircraft involved in private and charter operations are particularly at risk of experiencing fuel exhaustion or starvation due to poor fuel management.

Fuel exhaustion and fuel starvation are the two main reasons fuel stops going to the engine. Fuel exhaustion occurs when there is no useable fuel to supply the engine; fuel starvation happens when the fuel supply to the engine is interrupted although there is still enough fuel on board.

'The ATSB will continue to monitor this worrying trend and will work with relevant operators and pilots to help improve fuel management,' says Mr Dolan.

The ATSB has just released its latest Avoidable Accident report that helps pilots and aircraft operators better understand and manage fuel exhaustion and starvation. Starved and exhausted: Fuel management aviation accidents is available on the Safety Awareness section of the ATSB website at www.atsb.gov.au

The Australian Transport Safety Bureau has released its 2010-11 Annual Report.

'The report summarises a year of major activity and accomplishment for the ATSB, 'said the ATSB's Chief Commissioner, Martin Dolan. 'It also highlights a number of areas of continuing concern for transport safety.'

In its review of transport safety trends, the report highlights:

• a number of events involving 'see-and-avoid' procedures in the vicinity of smaller airports
• continuing issues with the training, checking and supervision of pilots
• the recurrence of known problems in general aviation, including collisions with powerlines, poor fuel management; and pilots flying visually into instrument conditions
• a pattern of problems, including a fatality, in the safe management of work on rail tracks
• the continuing risk to life of unsafe working practices in the maritime sector.

'These are potentially worrying trends', said Mr Dolan. 'We will continue to monitor them through our investigations and continue to bring them to industry's attention through our safety communication and education activities.'

During 2010-11, the ATSB completed 133 accident and incident investigations and commenced over 140 new investigations. Many of these attracted national and international interest, including the investigation into the uncontained engine failure on an Airbus A380 aircraft over Batam Island, Indonesia on 4 November 2010. The investigation identified fatigue cracking within a pipe feeding oil into engine bearing structures. As a result, prompt action was able to be undertaken to enable aircraft equipped with this engine type to resume safe flight.

Other investigations identified safety issues with the protection of Boeing 747-438 aircraft systems from liquids, waterproofing in AgustaWestland AW139 helicopters, potentially unreliable airspeed indications in Airbus A330 and A340 aircraft, the supervision of agricultural pilots, training and supervision of charter pilots, potentially hazardous helicopter winching procedures, turbulence caused by buildings at airports, airspace design and management and problems with the management by air traffic control of compromised separation of aircraft.

Significant surface transport investigations completed in 2010-11 include the 2010 grounding of the Chinese registered bulk carrier Shen Neng1; an investigation into the loss overboard of containers from the Pacific Adventurer, off Cape Moreton in 2009; and the grounding of the Atlantic Blue, which has led to a safety review of Australian coastal pilotage.

The ATSB Annual Report for 2010-2011 is available on the ATSB website at www.atsb.gov.au

On Monday 19 December 2011, the Australian Transport Safety Bureau (ATSB) will hold a media briefing to accompany the release of its final investigation report into the 7 October 2008 in-flight upset of an Airbus A330-303 that occurred 154 km west of Learmonth, WA.

ATSB Chief Commissioner Mr Martin Dolan will present the facts of the investigation and highlight the key safety actions that have resulted by the parties to prevent a recurrence.

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

Time: 10.30am (AEDT), Monday 19 December 2011

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

The incorrect entry of take-off weight data that resulted in the tail strike and runway overrun of an Emirates Airbus A340 aircraft was not a unique event. Similar events continue to occur throughout the world, according to the Australian Transport Safety Bureau (ATSB).

"These sorts of errors have potentially serious safety consequences," said ATSB Chief Commissioner, Mr Martin Dolan. "It is encouraging to see the significant safety action that is occurring as a result of the ATSB's investigation."

Mr Dolan was speaking on publication of the ATSB's final report of its investigation into a 20 March 2009 accident, when flight EK407, with 18 crew and 257 passengers, sustained a tail strike and overran the runway end on departure from Melbourne Airport, Victoria.

The ATSB found that the accident resulted from the use by the crew of incorrect take-off performance parameters. The initial error was likely due to mistyping, when a weight of 262.9 tonnes, instead of the intended 362.9 tonnes, was entered into a laptop computer (or 'electronic flight bag') to calculate the aircraft's take-off settings. The error passed through several subsequent checks without detection.

The ATSB's investigation examined a number of systemic safety issues surrounding the accident. The investigation was supported by an ATSB research report titled Take off performance calculation and entry errors: A global perspective.

"We now understand what caused the error and why it wasn't picked up," Mr Dolan said. "We also know there have been a number of other accidents and incidents that involved similar errors in a range of different aircraft operated by different airlines around the world."

"All of those events had two basic elements in common: the error in entering the weight was not detected before take-off, and the degraded take-off performance was not detected until well into the take-off run, if at all."

Mr Dolan noted that, currently, the only checks in place to prevent these types of accidents are procedural and vulnerable to human error. "But a lot of work is being done to minimise the risk of similar events in future," he said.

"This includes developing technological aids to assist flight crew in recognising both when take-off parameters are inappropriate and when take-off performance is degraded below a safe level" noted Mr Dolan. "The aviation industry as a whole realises the seriousness of these issues and is working towards a solution."

To stress that further action is still needed with technological aids, the ATSB has issued a safety recommendation to the United States Federal Aviation Administration. It has also issued safety advisory notices to a number of international aviation organisations. These notices highlight the importance in the meantime of managing the problem pilots face in deciding whether the parameters calculated for a particular take-off are appropriate.

A full copy of the investigation report AO-2009-012 is available on the ATSB website.

On Friday 16 December 2011, the Australian Transport Safety Bureau (ATSB) will hold a media briefing to accompany the release of its final investigation report into the 20 March 2009 tail strike of an Airbus A340-541 at Melbourne Airport.

ATSB Chief Commissioner Mr Martin Dolan will present the facts of the investigation and highlight the key safety actions that have resulted by the parties to prevent a recurrence.

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

Time: 10.30am (AEDT), Friday 16 December 2011

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

ATSB investigations have resulted in many improvements to transport safety, according to a new research report, although problems with the procedures used to manage safety risk continue to be the most common issue in all three modes of transport.

The report examines safety issues-and resulting actions-identified by the ATSB across the aviation, marine and rail sectors during 20010-11.

From the ATSB's investigations, 121 safety issues (factors that could adversely affect the safety of future operations) were identified. The transport industry undertook 137 separate safety actions to deal with these issues.

ATSB Chief Commissioner, Mr Martin Dolan, said the report shows that industry is taking steps to address safety problems as they are identified.

"It's the ATSB's job to identify and point out where there are issues with transport safety," Mr Dolan said. "We are encouraged that the aviation, marine and rail industries are actively managing these issues by improving procedures, documentation and education, but more needs to be done."

Mr Dolan highlighted that inadequate procedures remained the greatest safety risk across all three modes of transport, as had been the case last year.

Fifty-one aviation safety investigations completed by the ATSB identified a total of 75 safety issues. Poor or insufficient procedures to manage safety risk were, the most common type of problem identified. Most of these issues were associated with flight operations.

The ATSB's 11 marine safety investigations identified 27 safety issues, with procedures standing out, once again, as the most common safety issue. Navigation procedures were the most common issue with safe marine operations.

Eight of the rail safety investigations conducted by the ATSB identified procedural problems as the main source of safety concern. The most significant safety issues involved the design and operation of procedures. Two of the three procedural issues that posed significant safety risk to ongoing rail operations concerned network operations.

A full copy of Safety issues and safety actions identified through ATSB transport safety investigations: 2010-2011 financial year is available on the ATSB website.