The Australian Transport Safety Bureau has been advised of a fatal aviation accident involving a Bell 206 Helicopter, VH-CSH, conducting locust control work, which occurred near Dubbo, New South Wales at about 2.30 local time today 22 November 2004.

The Bureau has been advised that regrettably, two occupants of the helicopter suffered fatal injuries, and a third occupant was seriously injured.

The ATSB will be conducting an on-site investigation.

All media contact to be directed to the ATSB's central office, details below.

The ATSB investigation into the fatal Piper Seneca accident on 11 November 2003, at Bankstown Airport has found that the aircraft banked right and speared into the ground during a go-around manoeuvre.

The aircraft was being operated on a multi-engine endorsement training flight with an instructor and student on board.

The aircraft was destroyed by impact forces and the post-impact fire. The student was fatally injured in the accident and the instructor received severe burns and died three and a half weeks after the accident.

The ATSB interim factual report finds that the engines were developing comparable levels of power and the propeller blade angles were consistent with the angle appropriate for the go-around phase of flight.

The investigation is continuing and will be clarifying some aspects with the aircraft manufacturer before finalising the draft report.

On 1 December 2003, the Minister for Transport and Regional Services signed an Instrument of Direction to the Australian Transport Safety Bureau (ATSB). That instrument directed the ATSB to `investigate the effectiveness of the firefighting arrangements for Bankstown Airport, as they affected transport safety at Bankstown Airport on 11 November 2003'. That investigation was conducted in conjunction with the accident investigation and a separate report (200305496) is expected to be issued in the next couple of months.

The interim factual report (200304589) is available from the website, or from the Bureau on request.

On 21 March 2003 the port main engine of the Australian cargo ship Searoad Mersey failed catastrophically leaving the vessel disabled in Bass Strait. The Australian Transport Safety Bureau (ATSB) has released its investigation report into the incident.

At 1612 on 21 March 2003, the roll-on/roll-off cargo vessel Searoad Mersey departed from Melbourne on a scheduled service to Devonport in Tasmania. By 1924 the ship had cleared Point Lonsdale and was heading in a south-easterly direction in Bass Strait.

At about 2118, the duty engineer received an engine room alarm and made his way to the engine room. During his subsequent inspection of the engine room, he found a main engine connecting rod lying on the deck on the inboard side of the port main engine. The port main engine had stopped and it was evident that there had been a catastrophic failure of one of the engine's piston assemblies.

A short time later the running main generator overheated and shutdown which caused the ship to black out. The generator had stopped as a result of the damage to the main engine which had caused a large loss of cooling water from the common cooling system.

By 2230, the ship's systems had been stabilised and the starboard main engine had been restarted. Searoad Mersey then proceeded back to Melbourne under its own power to arrive at Webb Dock in the morning of 22 March 2003.

The ATSB's report makes conclusions relating to the failure of Searoad Mersey's port main engine including:

• A casting flaw found in the piston skirt which failed initiated a fatigue crack which eventually caused the piston to fail in service.
• The vessel's maintenance system did not include a system for tracking the total operating hours of the main engine piston assemblies.
• The vessel's maintenance system did not include a procedure for crack testing the piston skirts in the areas stipulated by the manufacturer in a service bulletin.
• There was evidence to suggest that the engine type have had a history of piston skirt failures similar to that which occurred on Searoad Mersey.

The report also makes recommendations to the operators of Wartsila Vasa 32 engines and to Wartsila NSD in relation to the servicing of piston assemblies and the distribution of engine service bulletins.

Copies of the report may be downloaded from the website or obtained from the ATSB by telephoning 1800 020 616.

The ATSB has found that the third officer of the Panamanian tanker Port Arthur suffered a fracture of his cervical spine during a lifeboat drill on 20 October 2003. Three other crew in the lifeboat escaped serious injury when the boat fell 10 metres into Port Botany after its suspension hooks opened prematurely while it was being launched.

The Australian Transport Safety Bureau (ATSB) has released its investigation report into the accident which concludes that the lifeboat's on-load release hooks had not been correctly reset when the boat was last lowered. Lack of effective maintenance had made the hooks difficult to reset and their design made it difficult for the crew to confirm whether or not the hooks were correctly reset.

The ATSB's report recommends that manufacturers of lifeboats and on-load release systems ensure that shipowners and operators of ships are advised of on-load release system incidents and that design changes are promulgated to all vessels fitted with their equipment. The report also recommends that manufacturers of on-load release systems ensure ships using their equipment are provided with detailed instructions for the operation and maintenance of those systems.

Since it was formed in 1999, the ATSB has issued reports on four previous lifeboat accidents, three of which were also associated with improperly reset on-load release hooks.

In September 2002 the ATSB released a safety bulletin on lifeboat accidents which was widely distributed to the maritime community as well as to the International Maritime Organization. The bulletin points out that:

Relatively complex designs, together with a poor understanding of their operation by ship's crews, insufficient maintenance and less than adequate manufacturer's instructions have led to the involuntary release of one or both hooks. The largest number of accidents, just over half of those reported, were caused by the unintentional release of hooks while on-load.

With regard to ship's safety management systems, the report recommends that shipowners, ship operators and International Safety Management accreditation authorities ensure that, with respect to crew training, maintenance and operational safeguards, such systems contain procedures commensurate with the considerable risks associated with lifeboat on-load release systems.

Copies of the report may be downloaded from the website or obtained from the ATSB by telephoning 1800 020 616.

In a pro-active move to reduce the number of collisions between trading ships and commercial fishing vessels on the Australian coast, the Australian Transport Safety Bureau (ATSB) has launched an Australia-wide safety awareness campaign.

The campaign is designed to raise the awareness of commercial fishermen to the contributory factors which the ATSB has identified during its investigation of 21 collisions between trading ships and fishing vessels since 1990 that have ongoing relevance.

The aim of the campaign is to highlight some of the risks associated with fishing on the Australian coast. The ATSB is working closely with fishing industry peak bodies and officials in each state and territory to implement the campaign.

During the campaign, members of the ATSB's Marine Investigation Unit will be holding a series of informal face-to-face discussions with commercial fishermen in various fishing ports around the country to bring the contributory factors to the attention of the industry. The meetings will be held in major fishing ports around Australia over the next twelve months. The first meeting is scheduled to take place in the southern NSW port of Eden on 2 December 2004.

A series of informative articles will also be printed in commercial fishing industry magazines and newsletters, which will bring the ATSB's message to the attention of those fishermen who can't attend the meetings. The safety awareness articles will start to appear in the fishing industry magazines and newsletters early in the new year.

The ATSB will also be releasing a safety bulletin, which will discuss the Bureau's concerns. The safety bulletin will be sent to state/territory marine authorities and Registered Training Organisations (RTO), responsible for training fishermen in each state and territory, and it will be distributed during the meetings with the fishermen. It will also be able to be downloaded from the website.

Further information on the safety awareness campaign can be obtained by phoning the ATSB on 1800 621 372 or by emailing the Marine Investigation Unit at: marine@atsb.gov.au.

An ICAO audit of the ATSB has reported high satisfaction with Australia's legislative, organisational and training framework for aircraft safety investigation and the professional and efficient conduct of the ATSB investigations reviewed in detail.

The audit by the Montreal-based International Civil Aviation Organization (ICAO) was sought by the Australian Transport Safety Bureau to ensure that the ATSB met international best practice for aviation accident and incident safety investigation.

The ICAO audit team 'commended the positive and professional approach of the ATSB in proactively seeking the audit' and made a number of very positive findings.

For example, the team 'was highly satisfied with the legislative and organizational framework established by Australia and the ATSB enabling the conduct of aircraft accident and incident investigations' in particular through the Transport Safety Investigation Act 2003 and Regulations.

The ICAO team 'commended' the ATSB's 'very comprehensive training policy and programme' and, based on the two complex accident investigations audited, found: 'despite multiple difficult circumstances in each of the investigations reviewed, the investigators appeared to have managed the investigation tasks in a professional and efficient manner, consistent with the established standards and practices of the ATSB. Furthermore & safety issues were properly addressed and the processing of reports of the investigations was generally accomplished in a timely manner'.

As expected, the audit team did make a number of recommendations for improvement including regarding documentation, memoranda of understanding, post-accident medical testing, budgeting and number of investigations, investigator training, and occurrence reporting, against which the ATSB has submitted a corrective action plan.

These recommendations are being progressed with the Minister and internally. In transmitting the audit report, ICAO stated that it was 'pleased to advise that your (the ATSB's) proposed corrective action plan was found to be fully acceptable'.

The field stage of the ICAO audit was conducted in May/June 2004 and the final audit report was transmitted this month. In the interests of transparency, the full ICAO audit report is available from the website, or from the Bureau on request.

At the request of the Queensland Government, the Australian Transport Safety Bureau has dispatched a team of Transport Safety Investigators to conduct an investigation into the Tilt Train Accident near Bundaberg which occurred in the early hours of 16 November 2004.

An initial team of three ATSB Transport Safety Investigators from Brisbane and Adelaide will be onsite this morning to commence the safety investigation.

The investigation will be run in conjunction with Queensland Transport.

Any person/witness with information about the derailment should contact the ATSB on 1800 020 616.

The Australian Transport Safety Bureau has dispatched a team of two investigators to determine the circumstances surrounding the fatal aviation accident near St George, 19 October 2004.

The factual circumstances to hand are that it was a private flight from Bundaberg to St. George, Queensland. During the flight, the pilot reported feeling unwell and disoriented. Another aircraft in the area was diverted to formate on the aircraft. The pilot was reportedly lapsing in and out of consciousness. The aircraft was followed, however it subsequently crashed SW of St. George. The pilot was fatally injured.

The investigation team is expecting to arrive at the site later this afternoon. The team will not be discussing the accident with media at this point in time.

Until further notice all media contact will be with the Bureau's central office, details below.

An ATSB report has found that a recent airspace incident was both an 'airprox' and a 'serious incident' and that after taking evasive action, a Cirrus SR20 and a Cessna 172 aircraft passed about 200 metres horizontally and 50 ft vertically from each other.

The Cirrus, operating under the instrument flight rules (IFR), was approaching the Cowes VHF omnidirectional radio range (VOR) navigation aid for instrument flight practice in visual meteorological conditions. A Cessna 172 aircraft, operating under the visual flight rules (VFR), was also conducting navigation aid practice using the Cowes VOR and non-directional radio beacon. Both aircraft were operating outside controlled airspace (in class G airspace), but within air traffic control radar coverage.

The pilot of the Cirrus contacted air traffic control and requested and obtained traffic information for his descent to 2,000 ft about an unverified aircraft operating at 1,900 ft in the area. The Cirrus pilot tried unsuccessfully to establish radio contact with the aircraft.

When approaching the Cowes VOR, the Cirrus pilot saw an aircraft on a reciprocal track at the same approximately 2,000 ft altitude. At about the same time, the Cessna pilot saw the Cirrus. Both pilots took evasive action. The pilots reported that the two aircraft passed about 200 metres horizontally and 50 ft vertically from each other.

The ATSB investigation found that the Cessna pilot had been on the radio frequency for operations within 40 NM south and south-east of Melbourne Airport. Consequently, he was unable to hear the Cirrus pilots broadcasts and develop an awareness of a possible conflict.

The radio frequency for the Cowes area was not published on the charts being used by the Cessna pilot. Airservices Australia had published an interim Frequency Planning Chart, which published the appropriate Air Traffic Services class E and class G radio frequencies, before this occurrence. However, the Cessna pilot did not receive the chart until sometime in July 2004 after this incident.

Airservices Australia advised the ATSB that it will re-introduce the publication of en route class G and class E radio frequencies and frequency boundaries on Aeronautical Information Publication charts effective 25 November 2004.

The full investigation report (200402065) is available from the website, or from the Bureau on request.

The ATSB's final investigation report into an airspace incident on 7 April involving a Boeing 737 and a Lancair aircraft has found that while it was an 'airprox' it was not a 'serious incident' because of timely action by the air traffic controller and both crews.

The Boeing 737, operating under the instrument flight rules (IFR), was en route from Townsville and descending for a landing at Brisbane. A Neico Lancair IV-P aircraft, operating under the visual flight rules (VFR), was en route from Maroochydore to St George, on climb to flight level (FL) 165.

Both aircraft were operating in Class E airspace when the 737 crew observed a TCAS traffic symbol and received subsequent TCAS alerts. This airspace was introduced as part of the National Airspace System (NAS) phase 2b from 27 November 2003.

Despite the assistance of air traffic control to both crews, the 737 crew had observed the Lancair's traffic symbol on the TCAS display but could not see the Lancair. They decreased the rate of descent and after receiving TCAS traffic advisory (TA) and resolution advisory (RA) alerts, climbed the 737 to FL166 and turned about 15 degrees right of track. Recorded Air Traffic Services (ATS) radar data indicated that the Lancair altered track 8 degrees to the right away from the 737 just before passing behind and below the 737. The minimum distance between the two aircraft was about 600 ft vertically at about 0.3 NM (about 556 metres) laterally.

Information obtained from the crews of each aircraft, the ATS controller, recorded flight data from the 737, ATS audio recordings and radar data, was consistent. Based on all of the circumstances, the incident was classified as an 'airprox' but not a 'serious incident'.

The investigation found that the crews of both aircraft and the air traffic controller complied with the published procedures for Class E airspace under NAS 2b.

Airservices Australia advised it had subsequently issued a national instruction and an information circular on safety alerts, traffic avoidance advice, and traffic information. It had also produced a computer-based training program for air traffic controllers on duty of care, which provided advice on when a safety alert is to be initiated.

The full investigation report 200401273.