A joint investigation carried out by the Australian Transport Safety Bureau and the Marshall Islands Maritime Authorities has found that a lack of preparedness, communication and supervision; and the incorrect use of the mooring winch brake were contributing factors in the death of a crew member on board the Marshall Islands flagged ship Probo Bear on 10 April 2006.

At 2150 on 10 April, the crew on board the products/ oil/bulk/ore carrier Probo Bear prepared to shift the ship forward, to position its number seven cargo hold under the Groote Eylandt jetty fixed loading boom. The weather was fine with light winds and there was little tidal flow.

At 2212, the master ordered the forward spring lines and stern lines be slackened, and to commence heaving on the head lines and aft spring lines. The main engine was run slow ahead for about ten seconds to start the ship moving.

During the shift ship operation one of the forward spring lines became taut. The master ordered the forward mooring crew to slacken the taut spring line, but it did not slacken off. The master ordered dead slow astern on the main engine to halt the ships movement. Just under a minute later, when he noted that the taut spring line had suddenly become slack, the master ordered the engine stopped.

A short time later, the crew member operating the number two forward spring line was found lying on the forecastle deck to the port side of the spring winch platform. He had severe head injuries and his safety helmet had been split in half. None of the crew on the forecastle had seen what had happened, but they had heard what sounded like a mooring line moving swiftly through the air.

A medically trained crew member was sent to the forecastle while the master informed the local authorities. The crew completed the mooring operations and paramedics boarded the ship when it was all fast at 2300. The crew member was confirmed dead at 2304.

The ship completed its cargo operations without further incident and sailed on 12 April 2006.

The investigation report makes recommendations to ship managers and masters in relation to the need for preparedness, communication and supervision during mooring operations.

The ATSB has announced that it will refer Lessbrook Pty Ltd to the Director of Public Prosecutions for its failure over several years to report aviation safety occurrences to the bureau as required by legislation.

Lessbrook Pty Ltd operates under the name Transair and was the operator of the aircraft in which two pilots and 13 passengers lost their lives on 7 May 2005. Despite the accident, it is only in recent weeks that Lessbrook has provided the Australian Transport Safety Bureau with evidence which our analysis has shown includes 25 safety incidents which should have been reported immediately or within 72 hours depending on their severity.

The unreported occurrences include 7 immediately reportable matters (IRMs) that occurred between 1 July 2003 and the accident. They include a gear failure on departure from Bamaga, a cabin pressurisation warning near Cairns, a burning smell near Inverell, and a problem with flaps leading to a flapless take-off and associated flight issues from Gunnedah to Sydney.

Under the Transport Safety Investigation Act 2003 (TSI Act) and Regulations such IRMs must be reported immediately by responsible persons (eg the airline operator) in accordance with the regulations and failure to do so has a maximum penalty of imprisonment for six months (Section 18 of the TSI Act). Failure to report the more routine matters or to make a written report of IRMs carries a maximum penalty of 60 penalty units, a very steep fine.

While in accordance with international requirements and domestic law, ATSB investigations do not seek to assign blame or liability, a serious breach of the TSI Act with respect to the investigations or reporting requires action to deter people from failing to comply with its safety objectives.

The failure to report these occurrences, which were reported by relevant pilots to the operator, is indicative of a poor safety culture and poor safety system within the operator. However, the reports are a separate safety issue compared with the fatal accident.

Despite the difficulties the ATSB has had in obtaining timely and complete information for its investigation, a draft of the final report is planned to be released to directly involved parties on 15 December. This is to enable checking of factual accuracy and to ensure natural justice. There are 60 days to comment before the ATSB finalises the report for public release.

This media release constitutes a report released under Section 25 of the TSI Act.

The ATSB has found that a misunderstanding between the master and pilot, and the lack of planning by the ship's crew were contributing factors in the grounding of the Liberian flagged general cargo ship Mellum on 28 September 2004.

The Australian Transport Safety Bureau investigation found the master/pilot information exchange was deficient, and that the insets and scales of the navigation chart in use may have contributed to the grounding.

At 1124 Australian Central Standard Time on 28 September, the general cargo ship Mellum let go from the wharf at Thevenard and headed to sea with a pilot on board. The sky was overcast and there was occasional light rain, but visibility was good. The wind was from the southeast at about five knots and the tide was flooding at about one knot.

At about 1217, the ship cleared Yatala Channel beacons one and two at a speed of about seven knots. Shortly thereafter, with the entrance beacon on the starboard bow, the pilot informed the master that he intended to disembark as they had earlier agreed. The master moved to the bridge wing and watched as the pilot disembarked the ship. He then returned to the wheelhouse and ordered the helmsman to steer a course of 222 by gyro compass.

The master soon noticed that the ship was to the south of the intended track and ordered a course of 225. At 1233, before this last order could be executed, the ship grounded just south of the entrance beacon.

The master stopped the main engine and then tried various manoeuvres to free the ship. He then called the pilot boat to request assistance. At 1320, the pilot reboarded the ship. Ballast water was moved and discharged from the ship to lighten it and change the trim.

Manoeuvres with the assistance of a local tug were carried out when the rising tide allowed, and at 2309 the pilot reported that the ship was afloat.

At 1500 on 30 September the detention order that had been issued after the grounding was lifted when the ship had been checked for damage and seaworthiness. At 1606, Mellum weighed anchor and sailed for Melbourne.

The ATSB has made a safety recommendation to Flinders Ports in relation to pilot training with the aim of preventing further incidents of this type.

An ATSB investigation report has found that while an emergency passenger evacuation at Hobart was conducted rapidly and in a pro-active manner in the interests of passenger safety, there were problems with communication involving the pilots, ground crew, and cabin crew that created potential risk and has led to improved safety action for the future.

The Australian Transport Safety Bureau's final report into the Boeing 717 evacuation on 17 May 2005 found that a right engine starter had failed during the engine start due to loss of lubricating oil because a seal retaining ring was incorrectly installed. This resulted in smoke and sparks issuing from the right aircraft engine. The smoke and sparks were reported to the captain as a fire by the aircraft dispatcher, and the captain ordered an emergency evacuation.

The 3 floor-level aircraft doors were opened by the flight attendants but when the right front door was opened, the escape slide fell to the ground uninflated. The investigation found that the escape slide may not have been properly armed after the doors were closed and that this was not noticed when visually cross-checked. (The passenger operated over-wing exits were not used as there were no passengers sitting in these rows.)

All 26 passengers successfully exited the aircraft in less than 64 seconds, but 11 reported sustaining minor injuries.

The emergency evacuation was ordered before the relevant checklist had been completed. This resulted in a lack of emergency lighting in the rear emergency area and delay in the extension of wing flaps that would have been necessary had the over-wing exits been used.

As a result of this incident, the operator has undertaken several safety actions to enhance passenger safety. These include: improved aircraft maintenance procedures relating to markings on door slide brackets; defined phraseology to be used in emergency communications between aircraft dispatchers and pilots; door closure procedures for engine starts; improved policy on cockpit discussion restrictions after door closure; and improved cabin crew procedures and training.

An ATSB has found that inadequate load securing methods, combined with reduced track clearances, lead to a collision between a steel plate freight load and a passenger train at Eden Hills station platform on 30 September 2005.

The freight load had been protruding from the side of the freight train for at least 85 km before the collision occurred.

Eden Hills is located about 14 km south of Adelaide in the Adelaide Hills region. Both trains were heading towards Adelaide when the collision occurred.

There were no injuries and only minor damage to track and rollingstock infrastructure.

The Australian Transport Safety Bureau investigation determined that the minor collision occurred as a result of movement of an inadequately secured metal plate load and reduced clearance between both tracks. Given the inadequate load securing methods, the risk of a load shift and strap failure, a collision became likely irrespective of track clearances.

As part of the investigation, the ATSB issued a safety advisory notice on 26 October 2005 to encourage better load security.

In the interest of future rail safety, the ATSB has now made further recommendations regarding the use and application of tensile strapping to ensure load security, reviewing acceptance and audit procedures to ensure load security, and reviewing standards and procedures to mitigate against reduced track clearances.

Read the report: Collision between Freight Train 5MA5 and Passenger Train 206A

The ATSB's on-site investigation into the 5 October 2006 fatal accident involving a BAC-167 Strikemaster jet, NE of Bathurst, NSW, is continuing. Access to the accident site has been hampered by the presence of a large bushfire, which is currently being fought by the NSW Rural Fire Service.

The Australian Transport Safety Bureau's on-site investigation team has reported that the aircraft wreckage trail extends more than 1 kilometre. Team members have been able to access some of the aircraft wreckage during a period of limited access to the accident site over the last 2 days. During that time, the team located and examined the aircraft's right wing and reported that the wing had separated from the aircraft fuselage in-flight.

At this stage, the ATSB does not know where in the wreckage trail sequence the wing is located, or the reason for the separation.

ATSB investigators will continue their work at the accident site over the coming days, subject to gaining safe access. Investigators have also been accessing the operator's aircraft maintenance and operational documentation. A preliminary factual report will be issued in about 30 days.

Witnesses are asked to call the ATSB on 1800 020 616.

An Australian Transport Safety Bureau (ATSB) investigation has found that a lack of hazard awareness and safety control measures led to the chief engineer on board the Australian bulk carrier River Embley sustaining burns to 45 percent of his body when he was scalded by hot water that unexpectedly sprayed from a steam valve he and a junior engineer were working on.

On the morning of 14 October 2005, the engineers were working in the engine room while the ship was at anchor off Gladstone. While they were dismantling the turbo alternator exhaust steam valve a thousand litres of pressurised hot water unexpectedly started to spray from the valve and onto the chief engineer standing on staging below.

In an effort to escape the hot water spray the chief engineer tried to jump clear of the staging but became entangled in the securing rope which had formed a barrier.

The ship's crew mounted an immediate first aid response and the master organised a helicopter evacuation. The chief engineer was transported to Gladstone Hospital and later transferred to the Royal Brisbane Hospital intensive care unit.

The report concludes that the engineers did not fully assess the exhaust steam piping system and its drainage arrangements, or allow sufficient time for the exhaust steam system to completely drain before starting to work on the valve.

The ship's work permit system and job safety analysis procedures were not utilised by the engineering crew and deficiencies in safety management were not identified in two audits prior to the accident.

It is also considered that a sizable experience gradient between the chief engineer and the other engineers along with a lack of training allowed a series of 'single person' errors to go unchecked and unquestioned.

The ATSB has made several safety recommendations aimed at preventing further accidents.

The ATSB has released a further Interim Factual Investigation Report into the Lockhart River accident on 7 May 2005 in which both pilots and all 13 passengers perished and says that it expects to complete its draft final report by the end of November.

This is the third factual report issued by the Australian Transport Safety Bureau since the tragic accident and, in accordance with international convention, it contains no analysis. The ATSB has previously issued a number of safety recommendations arising from the accident and others will be considered ahead of the final report if or as needed.

The ATSB is today also issuing research papers providing data on fatal accidents in Far North Queensland compared with other regions and on surveyed pilot perceptions of difficulties with the type of approach made in the bad weather of the accident flight.

This Interim Factual report also includes additional information relating to wreckage and the aircraft, the flight data recorder factual report, and a summary of survey and other research dealing with area navigation global satellite positioning system (RNAV (GNSS)) approaches.

The investigation is continuing and in addition to drafting of the final report - which will contain detailed analysis - will include further work on: the operator's management processes, standard operating procedures, flight crew training and checking, and document control; regulatory oversight of the operator's activities, including approvals and surveillance undertaken; the design and chart presentation of RNAV (GNSS) approaches; and desired action to enhance future safety.

The ATSB expects to complete a draft final report by the end of November 2006. To ensure factual accuracy and natural justice, directly involved parties in Australia and internationally will have 60 days to comment on this confidential draft. Contingent on the extent and timing of comments received, the ATSB plans to release its final report to the public in March 2007 after advance notice is given to the families of the deceased.

While the long-time taken for the investigation is regretted, the Bureau seeks understanding on this because it is Australia's worst civil aviation accident since 1968 and, in addition to the destruction of the aircraft, the investigation team does not have the benefit of a cockpit voice recording, survivors, or witnesses. For the sake of those who lost their lives and their friends and loved ones, and in the interest of future safety, the ATSB wishes to undertake as thorough an investigation as possible in the circumstances.

Copies of the latest Interim factual Aviation Safety Investigation Report 200501977 can be downloaded from the website.

An Australian Transport Safety Bureau (ATSB) investigation found that the collision between the Australian registered tug Tom Tough and the Panamanian registered bulk carrier Global Peace resulted in a spill of approximately 25 cubic metres of oil in Gladstone Harbour on 24 January 2006.

At about 2130 on the evening of 24 January, Global Peace entered Gladstone harbour for the transit to the Clinton Coal Terminal. The plan was for the ship to berth at Clinton number three berth with the assistance of three z-peller tugs.

As the ship was approaching the berth, the pilot asked all three tugs to stop pushing and to lay alongside. The master of the aft tug, Tom Tough, laid the tug alongside the ship, with the tug at an angle of about 15 degrees to the ship's side. The tugs bow was in line with the front of the ships accommodation.

At about 2354, Tom Toughs starboard main engine unexpectedly shutdown. The tug's stern swung sharply to starboard and the starboard quarter made heavy contact with the side of the ship, piercing the ship's shell plating.

The tug had punctured the ship's port heavy fuel oil tank. Oil immediately began to flow into the harbour. The flow of oil continued for about 45 minutes.

According to the ATSB investigation report, a cracked starboard main engine clutch oil pipe resulted in the tug's clutch system being emptied of oil. The resultant loss of system pressure activated the main engine shutdown.

The report concludes that the tug's procedures and associated risk analysis had not adequately addressed the risks associated with the engineer spending protracted periods of time out of the engine room, the engine room alarm and monitoring system did not adequately alert the tug master to the engine shutdown, and the towage company had given little thought to the possibility of further fatigue related failures after the failure of the clutch oil pump discharge pipe fitted to the port main engine in February 2002.

The investigation also found that the tugs aft fender arrangement did not provide adequate protection to the tug or the ship and that the ship's port deep fuel oil tank was not protected from a collision.

The ATSB found that the towage company had no system of professional development in place to ensure the ongoing training and performance monitoring of tug masters.

The ATSB has made several safety recommendations with the aim of preventing further incidents of this type.

An ATSB discussion paper has found that from 1990 to 2005 Queensland had a higher fatal aviation accident rate than the rest of Australia but that the results for Tasmania were much worse, and that the fatal accident rate for Far North Queensland was better than for Queensland's North and Central regions.

Like NSW/ACT, QLD was the location for 102 of the 318 fatal accidents in Australia from 1990 to 2005.

Compared with the national rate of 0.7 fatal accidents per 100,000 landings 1990-2004, TAS had 1.8 and QLD the next highest at 0.9. QLD had 32% of the accidents and 24% of the landings so its rate was higher than the rest of Australia.

The Australian Transport Safety Bureau initiated a research project to see if Far North Queensland (FNQ), where the 15-fatality Lockhart River accident occurred in 2005, was over-represented in longer term accident data and has found mixed results.

Using Australian Bureau of Statistics definitions for the regions, the ATSB found that the fatal accident rate for the South region was 0.7 per 100,000 landings, the same as the national average, but Far North Queensland was 1.0 and both Central and North 1.2.

However, in Far North Queensland 50 per cent of the fatal accidents involved Charter operations and because more passengers were on board, FNQ had the highest fatality rate among Queensland regions.

The ATSB noted a number of limitations with the data including that the location of the accident may have no safety significance. For example, the so called 'ghost flight' involving a chartered Beech King Air in 2000 travelled from southern WA across the NT before running out of fuel and crashing near Burketown, QLD with 8 fatalities.

The ATSB Research Discussion paper also notes the influence of weather, geography and other physical and environmental factors and makes some comparisons among regions in QLD and WA.

Copies of Discussion Paper B2006/0034 can be downloaded from the website, or obtained from the ATSB by telephoning (02) 6274 6425 or 1800 020 616 and comments addressed to the Deputy Director, Information & Investigations by 3 October are welcome.