ATSB investigates aircraft accident near Broken Hill

The ATSB has commenced an investigation into an aircraft accident involving a Cessna 172 that occurred about 110 km south of Broken Hill in NSW.

The aircraft was reported missing on Monday, 21 June after it departed from Woolcunda Station in NSW earlier that day. It was found by search and rescue crews this morning, partially submerged in a lake.

The status of the pilot, the only person on board, is not yet known. NSW Police are travelling to the scene.

The ATSB has dispatched four investigators to the accident site. They expect to be at the site for three to four days.

ATSB investigates bulk carrier grounding

The Australian Transport Safety Bureau (ATSB) is investigating the 3 April grounding of the Chinese flagged bulk carrier Shen Neng 1 at Douglas Shoal off the Queensland coast.

Shen Neng 1 was bound for China before grounding on the reef around 36 nautical miles east of Great Keppel Island. The ship has sustained damage to a number of its water ballast and fuel tanks.

The ATSB sent three marine investigators to Gladstone, Queensland on Sunday to begin the onsite phase of the investigation. The investigators have already interviewed people ashore and collected evidence. They will board the ship today to collect further evidence and interview crew members.

A preliminary ATSB investigation report will be released in around 28 days outlining the facts as known up to that time. A full report will be released after the investigation is completed.

The Australian Maritime Safety Authority (AMSA) has a casualty coordinator on board the ship and a salvor has been appointed to assess the salvage operation. Three tugs and oil spill response vessels are at the scene.

The ATSB will work closely with AMSA, Maritime Safety Queensland, and the Great Barrier Reef Marine Park Authority while conducting the investigation.

The ATSB is the Commonwealth's no-blame transport safety investigation agency. It investigates safety occurrences in the aviation, marine and rail sectors with an emphasis on identifying safety issues and improving safety. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.

Port Phillip gas pipeline rupture final safety report released

The ATSB has found that the submarine ethane gas pipeline rupture in Port Phillip on 13 December 2008 was the result of attempting to clear the container ship APL Sydney's anchor, which had snagged the pipeline.

The Australian Transport Safety Bureau investigation found the ship's anchor had been let go too close to the pipeline in the gale force winds and insufficient anchor cable was deployed. The anchor dragged towards the pipeline and snagged it because appropriate avoiding action was not taken.

At 1428 on 13 December, APL Sydney's anchor was let go in Melbourne's Outer Anchorage, about 1 km upwind of the pipeline and shortly afterwards, the pilot left the ship. By 1501, the ship had dragged its anchor and was located outside the anchorage, about 350 m from the pipeline. The master advised Melbourne harbour control of his intention to weigh anchor and shift the ship but was instructed to maintain position and wait for a pilot.

By 1525, the pilot had not boarded and the ship, after continuing to drag its anchor, was about 50 m from the pipeline. Harbour control then gave the master permission to shift the ship. Weighing anchor was started but after a few minutes, control of the ship was effectively lost. At about 1544, the anchor snagged the pipeline and a little later, the anchor windlass also failed.

The pilot re-boarded APL Sydney at 1603 and after first considering releasing the anchor cable, discussed the situation with harbour control. At 1615, he concluded the anchor was south of the pipeline and decided to drag it clear. The master accepted his plan and at 1620, the ship's main engine was started. At 1621, the gas pipeline ruptured. There were no injuries and the pipeline was isolated.

The investigation identified safety issues in relation to: the port's risk management with respect to the pipeline and anchorage boundaries and its shipping control procedures; the ship's safety management system; the pilotage company's safety management system; and the windlass failure.

The ATSB is pleased to report that safety actions to address all the safety issues have been taken or been proposed by the relevant parties to prevent similar incidents in the future. The risk assessment of the anchorage conducted by the Port of Melbourne Corporation and the implementation of measures, including revised anchorages with individual ship berths, is one of the significant actions taken.

Release of Shen Neng 1 preliminary factual report

On Thursday 15 April, the Australian Transport Safety Bureau (ATSB) will hold a media conference to accompany the release of its preliminary factual report into the grounding of the Shen Neng 1 off the Queensland coast.

ATSB Chief Commissioner Mr Martin Dolan will discuss the findings of the preliminary report.

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

Time: 10.30am (AEST)

The report will be available via the ATSB website (atsb.gov.au) at 10.30am on Thursday 15 April. Hard copies will also be available at the briefing. After this briefing, all media enquiries should be directed to the media phone number below.

ATSB welcomes appointment of new Commissioner

The Australian Transport Safety Bureau (ATSB) today welcomed the appointment of Ms Carolyn Walsh as the newest member of the ATSB Commission, effective from 8 March 2010.

Appointed by the Minister for Infrastructure, Transport, Regional Development and Local Government the Hon Anthony Albanese, Ms Walsh has a wealth of experience in the area of transport safety.

Most recently, Ms Walsh was Chief Executive of the Independent Transport Safety and Reliability Regulator in New South Wales.

The ATSB's Chief Commissioner, Mr Martin Dolan, said he welcomes the expertise and experience Ms Walsh brings to the Commission.

"Ms Walsh will make a significant contribution to the ATSB's work and ultimately to transport safety in Australia," Mr Dolan said.

"I look forward to working with Ms Walsh as we position the ATSB to support and advance the national transport safety agenda."

Ms Walsh will hold the part time Commissioner's position for the next three years.

The ATSB is the Commonwealth's transport safety investigation agency. It investigates safety occurrences in the aviation, marine and rail sectors with an emphasis on identifying safety issues and improving safety.

ATSB recovers aircraft flight recorders

The ATSB has recovered the flight data and cockpit voice recorders, or 'black boxes' from the Embraer 120 Brasilia aircraft that crashed at Darwin Airport, Northern Territory on Monday 22 March 2010.

The recorders have been transported to the ATSB's technical facilities in Canberra for analysis.

The ATSB investigation team is currently at the accident site examining and recording the on‑site physical evidence, interviewing witnesses and other involved parties, and examining the available third-party recordings and documentation. The team is expected to complete the on-site phase of the investigation later this week.

A preliminary factual report outlining the facts to date, and highlighting the future lines of enquiry, will be made available to the public on the ATSB's website in about 30 days.

Photographs of the crash site and recorders are on the investigation page of the ATSB's website.

Media briefing: Aircraft accident at Darwin Airport

The Australian Transport Safety Bureau (ATSB) is investigating the accident involving an Embraer Basilia aircraft (registration number VH-ANB) at Darwin Airport, Northern Territory, which occurred at 1010 CST on 22 March 2010.

The ATSB investigator in charge, Mr Alex Hood will conduct a briefing on known factual aspects of the aviation accident.

Where: Outside RAAF Base Darwin, NT (Cnr of Stuart Hwy and Billeroy Road)

Date: Tuesday 23 March 2010, 1400 CST (local time)

No further media briefings will be conducted by the investigation team. After this briefing, all media enquiries must be directed to the media contact listed below.

Mishandled air manoeuvre prompts changes to procedures

An aircraft operator has changed its operating procedures following a go-around during an attempted landing at Melbourne in July 2007. The aircraft manufacturer has also revised some of its procedures for the aircraft type.

A passenger aircraft had attempted to land at Melbourne airport in fog, but abandoned the landing due to low visibility. During the go-around, the aircraft descended to within 38 feet of the ground before climbing.

An Australian Transport Safety Bureau (ATSB) investigation report, released today, found that the go-around did not work as intended due to a combination of:

  • problems in positioning the thrust levers for the aircraft's engines
  • failure of the aircraft's flight computers to switch to go-around status and
  • the way tasks were sequenced in the operator's go-around procedures.

The ATSB investigation also found that reporting of the occurrence had not met the requirements of the Transport Safety Investigation Act 2003.

This incident has prompted the operator to change its go-around procedures. The aircraft manufacturer has also changed its published procedures to emphasise some crucial flight crew actions in go-around manoeuvres.

The Chief Commissioner of the ATSB, Mr Martin Dolan, said that the investigation was a good example of how safety investigators could work with operators to improve transport safety.

"We can often learn as much or more from occurrences like this as we can from investigating tragic accidents," Mr Dolan said. "A thorough analysis of what happened, and why, can contribute to improved safety, as it did in this case."

"I would like to remind all transport operators that doing our safety job well relies, in part, on the timely reporting of accidents and incidents," Mr Dolan added.

Full details of the incident and investigation can be found in ATSB's investigation report (Report number AO-2007-044).

Media briefing—mishandled go-around at Melbourne airport

On Friday 5 March 2010, the Australian Transport Safety Bureau (ATSB) will hold a media conference to accompany the release of its final investigation report into a mishandled go-around procedure, involving an Airbus A320-232 passenger aircraft (registered VH-VQT). The incident occurred during a landing attempt at Melbourne airport on 21 July 2007, following a scheduled flight from Christchurch, New Zealand.

The ATSB's Chief Commissioner, Mr Martin Dolan, and Team Leader, Aviation Safety Investigations, Mr Joe Hattley, will discuss the report. Mr Dolan and Mr Hattley will also share the key safety lessons learnt from the investigation.

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

Time: 11.00am (ADST)

The report will be available via the ATSB website (atsb.gov.au) at 10.30am on Friday, 5 March.  Hard copies will also be available, at 10.30am, for media representatives attending the briefing. No further media briefings will be conducted by the investigation team. After this briefing, all media enquiries should be directed to the media phone number below.

Tailstrike Melbourne Airport, Vic. 20 March 2009 A6-ERG Airbus A340-541

The Australian Transport Safety Bureau (ATSB) is releasing its Interim Factual report into the tailstrike involving Airbus A340-500 aircraft, registered A6-ERG, during takeoff at Melbourne Airport, Vic. on the evening of 20 March 2009. The aircraft was being operated on a scheduled passenger flight from Melbourne to Dubai in the United Arab Emirates. This report builds on the facts advised in the report that was released on 30 April 2009 (ISBN 978-1-921602-43-6, available at www.atsb.gov.au).

The investigation has determined that the pre-flight take-off performance calculations were based on an incorrect take-off weight that was inadvertently entered into the aircraft's portable flight planning computer by the flight crew. Subsequent crosschecks did not detect the incorrect entry and its effect on performance planning, and the resulting take-off speeds and engine thrust settings that were applied by the crew were insufficient for a normal takeoff.

As a result of this accident, the aircraft operator has undertaken a number of procedural, training and technical initiatives across its fleet and operations; with a view to minimising the risk of a recurrence. In addition, the aircraft manufacturer has released a modified version of its cockpit performance-planning tool and is developing a software package that automatically checks the consistency of the flight data being entered into the aircraft's flight computers by flight crews.

The investigation has found a number of similar take-off performance-related incidents and accidents across a range of aircraft types, locations and operators around the world. As a result, the ATSB has initiated a safety research project to collate those events and examine the factors involved. The findings of that project will be released by the ATSB once completed.

The ATSB continues to work closely with the United Arab Emirates General Civil Aviation Authority (GCAA), the French Bureau d'Enquetes et d'Analyses (BEA), the operator and aircraft manufacturer. Ongoing investigation effort will include the examination of:

  • computer-based flight performance planning
  • human performance and organisational risk controls
  • reduced thrust takeoffs and the use of erroneous take-off performance data.

The remainder of the investigation is likely to take some months. However, should any critical safety issues emerge that require urgent attention, the ATSB will immediately bring such issues to the attention of the relevant authorities who are best placed to take prompt action to address those issues. In the interim, the ATSB has drawn this interim report to the attention of operators to remind them of the risks associated with calculating and entering take-off performance information.