The rate of fatal accidents in general aviation is 3½ times higher than for air transport activity according to an ATSB report.

Released today, the statistical report examines aviation accidents and incidents between 2001 and 2010 across all aviation types in Australia.

During the past ten years, there were 236 people killed in 147 fatal accidents in general aviation. General aviation includes all VH-registered flying activities except scheduled and charter passenger and freight operations.

Within general aviation, private flying accounted for the highest number of fatalities at 135 people between 2001 and 2010.

ATSB Chief Commissioner, Mr Martin Dolan, said anyone involved in general aviation, and private pilots in particular, should take heed of these findings.

"This report is a startling reminder of the dangers facing private pilots and general aviation as a whole," Mr Dolan says. "What's more, many of these tragedies could have been avoided with simple risk management procedures."

Mr Dolan says the ATSB is focussing more effort on targeting general aviation with safety messages due to the high number of accidents in this area.

"We've been preparing a series of publications for general aviation and private pilots," Mr Dolan says. "We have drawn graphic attention to the consequences of doing risky things such as low flying, which has led to a series of fatalities over time.

"We are also assisting private pilots to better assess the set of risks they are facing and how to deal with this risks."

A copy of the statistical report, Aviation Occurrence Statistics, 2001 to 2010 is available on the ATSB website.

Fact sheet

Top five accidents and serious incidents (General Aviation)

1. Terrain collisions (e.g. ground strikes; wirestrikes)
2. Aircraft control (e.g. hard landing; loss of control; unstable approach; wheels-up landing)
3. Powerplant and propulsion (e.g. partial and total power loss; engine failure; propeller failure; transmission and gearbox issues)
4. Aircraft separation (e.g. breakdown of separation; mid-air collision)
5. Runway events (e.g. depart, approach, land wrong runway; runway excursion and incursion; runway undershoot)

Top five accidents and serious incidents (Air transport-fare-paying passenger aircraft)

1. Aircraft separation (e.g. breakdown of separation; mid-air collision)
2. Aircraft control (e.g. hard landing; loss of control; unstable approach; wheels-up landing)
3. Powerplant and propulsion systems (e.g. partial and total power loss; engine failure; propeller issues; transmission and gearbox issues)
4. Miscellaneous events (e.g. crew incapacitation; depressurisation; missing aircraft; security issues; stall warnings; laser-related issues; unauthorised low flying; warning device issues)
5. Terrain collisions (e.g. ground strikes; wirestrikes)

You can also find a range of safety education material under the Publications tab on the ATSB's website at www.atsb.gov.au

ATSB investigations resulted in major improvements to transport safety, according to a new research report.

The report examines safety issues-and resulting actions-identified by the ATSB across the aviation, marine and rail sectors during 2009-10.

From the ATSB's investigations, 124 safety issues (factors that could adversely affect the safety of future operations) were identified. The transport industry undertook 141 separate safety actions to deal with these issues.

Overall, inadequate procedures or the lack of procedures posed the greatest safety risk across all three modes of transport.

ATSB Chief Commissioner, Mr Martin Dolan, said the report shows that industry is actively managing these risks. 

'I'm pleased to see that the aviation, marine and rail industries are actively responding to identified safety issues by improving procedures, documentation and education,' Mr Dolan said.

'By directly dealing with safety concerns, transport operators are helping ensure that accidents and incidents are not repeated.'

Of the 37 more complex aviation safety investigations completed by the ATSB, poor or insufficient procedures were the most common type of safety risk identified. Most of these issues were associated with flight operations.

The ATSB's 10 marine safety investigations found that procedures were the most common safety issues, mostly from the deck operations and navigation/pilotage areas.

The 11 rail safety investigations conducted by the ATSB identified safety practices and procedures as the most common safety issues, with vehicle maintenance and network operations being the areas most associated with significant risks.

A full copy of Safety issues and safety actions identified through ATSB transport safety investigations: 2009-2010 financial year is available on the ATSB website.

A new ATSB investigation bulletin released today highlights five instances of aircraft coming too close to each other.

Two of these occurrences were 'breakdowns of separation,' taking place in airspace under Air Traffic Control, which has carefully defined standards to keep planes a set distance apart.

Several safety actions have come out of these occurrences, including the establishment of an awareness program for Air Traffic Controllers, and a systemic review by Airservices Australia.

Mr Joe Hattley, the ATSB's Assistant General Manager of Aviation Safety Investigations says the investigations bulletin provides a useful resource for the aviation industry to help improve safety.

'The bulletin covers a range of the ATSB's shorter investigations and highlights valuable safety lessons for pilots, operators and safety managers,' Mr Hattley says.

Other investigations covered in the bulletin included a depressurisation event, two instances of total power loss and a situation in which fumes and smoke appeared in a plane's cockpit. As a result of a wirestrike, an aircraft operator is working to put together a database of powerlines.

Released quarterly, the bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken or identified. The bulletin also highlights important safety messages for the broader aviation community, drawing on earlier ATSB investigations and research.

Aviation Short Investigation Bulletin: First Quarter 2011 is available on the ATSB website.

Operators of Robinson R44 helicopters are being advised to inspect the security of their helicopters' hydraulic-boost servos following a fatal accident at Cessnock Aerodrome, NSW.

On 4 February 2011, a Robinson R44 Astro helicopter crashed after part of the aircraft's flight controls separated from the hydraulic-boost system during circuit operations. The pilot survived, but the flight instructor and a passenger died in the accident.

The Australian Transport Safety Bureau's (ATSB's) preliminary factual report, released today, reveals that a bolt securing part of the flight control system had detached, causing loss of control of the helicopter.

The preliminary results of the investigation have prompted the ATSB to urge operators of R44 hydraulic system-equipped helicopters to inspect and test the security of the flight control attachments on their R44 helicopters, paying particular attention to the connections at the top and bottom of the servos.

A hydraulic-boost servo makes it easier for the pilot to handle the flight controls-similar to power steering in a car.

Operators who find anything unusual on inspection of R44 flight controls are asked to contact the ATSB on 1800 020 616.

The investigation is continuing.

The ATSB will release a final investigation report within 12 months.

More information on the investigation is available on the investigation page AO-2011-016.

Ship operators need to ensure that they have an appropriate process in place to properly manage the level of crew fatigue according to the Australian Transport Safety Bureau (ATSB).

The advice is a result of the ATSB's investigation into the 3 April 2010 grounding of Chinese bulk carrier Shen Neng 1 on Douglas Shoal, off the coast of Queensland near Gladstone.

In its final investigation report, released today, the ATSB found that the chief mate was affected by fatigue and this resulted in a decreased level of performance while he was monitoring Shen Neng 1's position. The report found that the ship did not have an effective fatigue management system in place to ensure that the bridge watchkeeper was fit to stand a navigational watch. (A watchkeeper is responsible for navigating the ship).

ATSB Chief Commissioner, Mr Martin Dolan, said Shen Neng 1's grounding provides an important safety lesson for all seagoing vessels.

"Fatigue is one of the key safety risks facing seafarers, and watchkeepers in particular. Failure to manage fatigue can lead to loss of life, damage to property and damage to the environment," Mr Dolan says.

"The ATSB urges ship operators to comply with international requirements that ensure operators properly manage the hours of work and rest of watchkeepers."

The report also identifies several other safety issues relating to the accident:

• The ship's safety management system did not contain procedures or guidance in relation to the proper use of passage plans, including electronic route plans.
• In the 30 minutes leading up to the grounding, there were no visual cues to warn either the chief mate or the seaman on lookout duty, as to the underwater navigation hazards directly ahead of the ship.
• At the time of the grounding, the protections afforded by the requirement for compulsory pilotage and active monitoring of ships by the

Great Barrier Reef and Torres Strait Vessel Traffic Service (REEFVTS) were not in place in the sea area off Gladstone.

The report contains two safety recommendations addressed to Shen Neng 1's management company regarding the safety issues associated with fatigue management and passage planning. The report also acknowledges the safety action taken by the Australian Maritime Safety Authority in relation to the extension of REEFVTS coverage to include the waters off Gladstone.

The final investigation report into the Shen Neng 1 grounding.

The ATSB will conduct an onsite media briefing on its investigation into the 30 March 2011 fatal aircraft accident at Moree, NSW.

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

The ATSB has deployed four investigators, three from Canberra and one from Brisbane, who will arrive at Moree later today. Over the next few days they will examine the wreckage site, interview witnesses and collect maintenance records.

Where: Accident site (Blueberry Road, Moree)

When: 11.00am (AEDT), 1 April 2011

On Thursday 14 April 2011, the Australian Transport Safety Bureau (ATSB) will hold a media briefing to accompany the release of its final investigation report into the 3 April 2010 grounding of Chinese bulk carrier Shen Neng 1 on Douglas Shoal, off the coast of Queensland near Gladstone.

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

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

Time: 10.30am (AEDT), Thursday 14 April 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 importance of maintaining situational awareness and the risks of pilot distraction are two of the major safety lessons featured in the latest edition of the ATSB's investigation bulletin, released today.

Situational awareness was a factor in air proximity events, breakdowns of separation, ground handling and wirestrikes. An example of a situational awareness issue occurred when a Pilatus PC-12/45 and Aeronautica MacchiAL60 passed within close proximity to each other while flying. This incident highlighted the need for aircrew to conduct diligent radio broadcasts and continual visual scanning to minimise the risk of collision.

The bulletin also identified how pilot distractions can affect the safety of aircraft operations. This was highlighted when the pilot of a Cessna 206 was distracted by other traffic operating in the area and consequently did not change the fuel tank selection. This resulted in an engine failure and subsequent forced landing.

Other safety lessons featured in the bulletin cover:

• the importance of pilots using all available resources to confirm clearances from the air traffic control
• the importance of not over-extending an aircraft glide after an engine failure
• the difficulties associated with managing an in-flight engine failure at low altitude
• the steps pilots can take to avoid wirestrikes, especially when flying in unfamiliar areas
• the techniques pilots can use to maintain separation from other aircraft.

Released quarterly, the bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken or identified. The bulletin also highlights important safety messages for the broader aviation community, drawing on earlier ATSB investigations and research.

A copy of the Level 5 factual investigations: 1 October 2010 to 31 December 2010 bulletin.

Aircraft take-off performance errors resulting from simple human data calculation or entry occur too frequently but can be avoided or detected, according to an ATSB research report, released today.

The report examines Australian and international occurrences between 1 January 1989 and 30 June 2009 that involved the calculation and entry of erroneous take-off data. It reveals that take-off errors happen for many different reasons such as the wrong figure being used as well as data being entered incorrectly, not being updated, or being excluded.

Importantly, the report identifies that while no one is immune from these types of events, risk can be dramatically reduced through good operating procedures, aircraft automation systems and software design, and clear and complete flight documentation.

The consequences of these sorts of errors can range from aborted take-offs through the tail of the aircraft scraping the runway and, in the extreme, collisions with the ground.

ATSB Chief Commissioner, Mr Martin Dolan, said that while there is no single solution to preventing take-off performance calculation and entry errors, good operating procedures will help to mitigate the risks associated with these errors.

'With each operator using different take-off calculation methods on different types of aircraft, there will never be one solution for eliminating these errors,' Mr Dolan said.

'Good standard operating procedures, such as cross checking all take-off calculations or verifying data using multiple sources, will help detect any errors before the aircraft leaves the gate.'

'We advise operators to consider all the possible errors that could be introduced and then determine if the procedures in place will prevent these errors from occurring or provide opportunity to be detected.'

This ATSB research report expands on previous research by the Laboratory of Applied Anthropology, Boeing and Airbus by providing both an Australian and international perspective on these events. The report also explores why these events occurred by analysing the contributing safety factors.

A copy of the research report, Take-off performance calculation and entry errors: A global perspective, is available on the ATSB website at www.atsb.gov.au

The Australian Transport Safety Bureau (ATSB) is urging shipping operators to regularly check and replace their container lashing equipment as a result of an incident involving the Hong Kong registered container ship Pacific Adventurer.

On 11 March 2009, Pacific Adventurer lost 31 containers overboard during severe weather and large swells off Cape Moreton, Queensland. As the unsecured containers went overboard, they holed two of the ship's fuel oil bunker tanks. This caused the ship to leak 270 tonnes of bunker oil into the sea which affected 70kms of Queensland's coastline.

The ATSB investigation into the incident found that much of the ship's loose and fixed container lashing equipment, which is meant to secure the containers to the ship, was in poor condition. In addition, the inspection and replacement regime of this equipment had not been effectively implemented.

ATSB Chief Commissioner, Mr Martin Dolan, said this incident highlights the importance for all operators to ensure their cargo is properly secured, especially before bad weather is expected.

'Unsecure shipping containers pose a major threat to life, property and the environment,' Mr Dolan said.

'All shipping operators should be regularly and systematically maintaining their lashing equipment to prevent a recurrence of the Pacific Adventurer incident.'

The ATSB also identified several other safety issues as a result of the investigation. These include:

• there was no requirement for a third party to inspect this lashing equipment
• the cargo in the containers lost overboard was not packaged in accordance with international dangerous goods shipping requirements
• the dangerous goods shipping compliance audit regime did not pick up on this fact.

The organisations involved have already addressed these issues.

A copy of the Pacific Adventurer investigation report MO-2009-002.