The Australian Transport Safety Bureau (ATSB) is releasing its Preliminary Factual report into the ditching that occurred 6 km to the west of Norfolk Island on the evening of 18 November 2009 and involved Israel Aircraft Industries Westwind 1124A aircraft, registered VH-NGA. The six occupants evacuated the aircraft as it sank, and were later recovered by a rescue vessel from Norfolk Island.

While the ATSB has yet to establish all the factors relevant to this occurrence, it nevertheless highlights the risks in operating long distance flights to remote island locations which are subject to rapidly changing weather conditions.

As a result of this accident, the aircraft operator commenced a program to check and revalidate the company's commercial Westwind pilots. The program addressed a number of aspects of the company's Westwind operations.

The ATSB has interviewed a number of witnesses and people who were associated with the occurrence, and is assessing the feasibility of recovering the aircraft Cockpit Voice and Flight Data recorders from the seabed.

The investigation is continuing and will include further examination and analysis of the:

• meteorological information and its effect on the decision making and actions of the crew during the flight
• fuel planning relevant to the flight
• operational requirements that were relevant to the conduct of the flight
• crew resource management
• aeromedical flight classification and dispatch.

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.

A bulletin released by the Australian Transport Safety Bureau (ATSB) today reveals that unauthorised and unnecessary low-level flying has contributed to the deaths of at least 12 people during the past 10 years.

The bulletin, the first in the series of the ATSB's avoidable accidents publications, presents case studies on the dangers of flying low. It also focuses on the key safety lessons learnt from each of these cases.

The ATSB's Director of Safety Data, Research and Technical, Mr Julian Walsh, said the bulletin aims to educate the flying community and general public about the inherent hazards of unauthorised low-level flying.

"The key lesson we've learnt from this report is that these tragedies were avoidable. Low-level flying is risky and should be avoided when there is no reason to do it," Mr Walsh said.

"When a pilot flies low they encounter obstacles, such as powerlines, that are difficult to see and difficult to avoid. There's also very little time to recover control of the aircraft if something goes wrong.

"I sincerely hope that pilots take heed of lessons detailed in this bulletin and consider the potentially tragic consequences of low-level flying."

The ATSB will release further bulletins from the avoidable accidents series in the future. The topics are based on trends in the types of accidents that have been reported to the ATSB.

On Friday, 18 December 2009, the Australian Transport Safety Bureau (ATSB) will be holding a media conference to accompany the release of its interim factual report into the tail strike involving Airbus A340-500 aircraft, registered A6-ERG, during take-off at Melbourne Airport, Vic. on the evening of 20 March 2009.

Mr Martin Dolan, Chief Commissioner of the Bureau, and Mr Ian Sangston, Director of Aviation Safety Investigations will discuss the report. Mr Dolan and Mr Sangston will also review the investigation activities conducted up to this point, and highlight the safety action already undertaken with a view to preventing a recurrence of the accident.

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

Time: 10:30 am (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.

The Australian Transport Safety Bureau (ATSB) held a media briefing near Dorrigo, NSW on the ATSB's investigation into the Bell 206 helicopter accident on 9 December 2009.

Senior Investigator Chuck Davies told the media that the investigation would seek to identify what factors may have contributed to the accident. The ATSB is also investigating two other incidents involving helicopter operations in support of firefighting efforts, that occurred near Bathurst and Tamworth this week.

The ATSB has dispatched a team of five investigators to Dorrigo. The team arrived on site early on 10 December and is expected to be on site for 3 to 5 days. The ATSB is working closely with the NSW police who are also on site.

During their time on site, the team will; examine the site including the available physical evidence, speak to any witnesses, and visit the aircraft operator to recover relevant operational and maintenance documentation. A number of items and components from the helicopter may be recovered from the site for later technical examination.

On return from the accident site, the investigation will continue gathering factual information including the weather at the time of the accident, any recorded data, and additional witness and other interviews. The investigation will then analyse the data before making any findings and, where necessary, will encourage safety action in order to prevent a recurrence of similar accidents.

It is too early to speculate about contributory and other factors relevant to this accident. Accident investigations can be complex and fatal accidents such as occurred at Dorrigo yesterday can take many months to finalise and to release the final investigation report to the public. However, a Preliminary Factual Report will be released in about 30 days.

Any witnesses to the accident are requested to contact the ATSB at tel: 1800 011 034 or 1800 020 616, or via email

On Thursday 19 November 2009, the Australian Transport Safety Bureau (ATSB) will be holding a media conference into the fatal accident involving VH-ZRR, a Cessna A188B, near Kojonup, WA on 17 Nov 2009.

The Investigator in Charge, Mr John Robins, will provide factual information in relation to the accident. Mr Robins will not be providing any analysis or possible contributing factors.

Where: Kojonup Apex Park, Corner Broomehill Road and Albany Highway, Kojonup, WA

Time: 11.00am (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.

Media Briefing at 2pm, 10 December 2009 at the Skywalk, Dorrigo National Park, Dorrigo NSW

Helicopter Accident involving a Bell 206 Helicopter (VH-MJO), near Dorrigo NSW on 9 December 2009.

The Australian Transport Safety Bureau (ATSB) is investigating the accident involving a Bell 206 Helicopter (VH-MJO), which occurred near Dorrigo NSW, on 9 December 2009.

ATSB Senior Investigator, Mr Chuck Davies, will discuss factual information known to the ATSB at this time and will outline the investigation process at a media conference today, Thursday, 10 December 2009.

Where: The Skywalk facility, Dorrigo National Park., near Dorrigo

Time: 2.00 pm (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.

On Wednesday, 18 November 2009, the Australian Transport Safety Bureau (ATSB) will be holding a media conference to accompany the release of its second interim factual report into the in-flight upset involving Airbus A330-303 aircraft, registered VH-QPA that occurred 154 km west of Learmonth, WA on 7 October 2008.

Mr Martin Dolan, Chief Commissioner of the Bureau, and Mr Ian Sangston, Director of Aviation Safety Investigations will discuss the report, which builds upon the facts released in the previous interim factual report, and details the safety actions taken as a result of the accident. Mr Dolan and Mr Sangston will also be talking about the investigation activities conducted up to this point.

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

Time: 10:30 am (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.

The Australian Transport Safety Bureau is continuing its rigorous and comprehensive examination of the circumstances surrounding the failure of an oxygen cylinder that led to the depressurisation of a Boeing 747 on a flight from Hong Kong to Melbourne in July last year.

The ATSB's second interim factual report on this accident, released today, indicates that to date there is no evidence of systemic safety problems with oxygen bottles of the type involved in the accident. Various tests have not been able to replicate the cylinder failure that initiated the accident.

The report provides details of the wide-ranging and ongoing technical examination of five oxygen cylinders obtained by the ATSB from the same manufacturing lot as the failed cylinder. The original cylinder was lost in the South China Sea in the course of the accident.

Analysis of the factual information and findings as to the factors that contributed to the accident remain the subject of ongoing work. Details will be included in the final report of the investigation.

To date, all pressure tests of the cylinders met or exceeded the relevant safety specifications, with recorded rupture pressures being over twice the maximum working pressure of the cylinders.

Other work is being carried out to determine the minimum size of mechanical flaws that could result in cylinder failure in service. The ongoing ATSB investigation will supplement that work with a program of rupture tests on cylinders that have had various sized 'artificial' flaws machined into the shell.

The ATSB expects to conclude the data gathering and analysis aspects of the investigation in early 2010, with a final report to follow.

The Australian Transport Safety Bureau (ATSB) has released its preliminary investigation report into the collision between the bulk carrier Silver Yang and the yacht, Ella's Pink Lady.

The report contains factual information gathered to date, as part of the investigation process.

ATSB investigators last met with the skipper of Ella's Pink Lady on 9 October 2009, prior to her departure on her round-the-world voyage.

The ATSB investigation is ongoing and will focus on several specific areas including:

• the electronic detectability of the yacht
• the lookout being kept on board both vessels
• adherence to the International Regulations for the Prevention of Collisions at Sea (COLREGS)
• collision risk assessment
• actions taken following the collision.

Since Silver Yang was enroute to China, ATSB investigators were unable to attend the vessel. However, the Hong Kong Marine Department has assisted the investigation by collecting and providing a range of material from the ship, including statements from the master and involved crew.

The final report is unlikely to be available for several months. Should any critical safety issues emerge that require urgent attention, the ATSB will immediately bring such issues to the attention of the relevant parties who are best placed to take prompt action to address those issues.

Once completed, the investigation report will be published on the ATSB website.

Media conference talking notes [PDF 80 kb]

Audio of media conference [MP3 audio 1500 kb]

The investigation of an in-flight breakup that occurred near Clombinane, Victoria on 31 July 2007 has found that it most likely resulted from an encounter with localised and intense turbulence, from an elevator control input, or from a combination of both. The accident resulted in the death of the pilot and passenger on board the Rockwell International Aero Commander 500-S aircraft on a business flight from Essendon Airport to Shepparton.

As a result of its investigation, the Australian Transport Safety Bureau reissued the publication Mountain Wave Turbulence (available for download at www.atsb.gov.au), distributed the investigation report to all Australian operators of the Aero Commander aircraft, and issued a safety advisory notice to aircraft operators and pilots. That notice encouraged aircraft operators to review their procedures to ensure an appropriate awareness amongst operating personnel of the implications for aircraft performance of the combination of aircraft weights and speed, and of the ambient conditions; in particular, when flying in, or near areas of forecast severe turbulence.

The investigation found that some pilots operating the aircraft type were generally unaware of the applicability of the aircraft's manoeuvring speed during flight through turbulence, despite the inclusion of relevant advisory information in the operator's documentation. There was also a concern that pilots generally may not have been exercising as much caution in forecast severe turbulence conditions as they would for thunderstorms, even though the intensity of the turbulence could be similar.

At the time of the in-flight breakup, special weather reports for severe turbulence and severe mountain waves were current for the area. Wind speeds on the ground were reported to be 50 kts and calculations using the recorded radar data and forecast wind showed that the aircraft had been in cruise flight at 7,000 ft above mean sea level at speeds probably greater than its published manoeuvring speed, prior to it disappearing from radar. The wreckage and its distribution pattern were consistent with an in-flight breakup during cruise flight.

There was no evidence of any pre-existing defect, corrosion or fatigue found in the aircraft structure. An examination of the wreckage and fracture surfaces showed that the aircraft structure failed under symmetrical negative overstress.

A full report is available from the ATSB website Aviation Occurrence AO-2007-029