The ATSB investigation Preliminary Report into the accident in which six lives were lost when a privately operated Piper Cheyenne aircraft crashed near Benalla, Victoria, on 28 July 2004, found that the aircraft was off course for a substantial period.

The aircraft departed Bankstown, NSW that morning, and travelled via Jervis Bay. The pilot then contacted air traffic control requesting a track from abeam Ulladulla to Benalla. The route flown did not pass directly over any ground based navigation aids and the pilot relied on the global positioning system (GPS) for navigation and for the approach, through cloud, to Benalla.

Recorded radar data indicated that the aircraft's track was a consistent 3.83 degrees left of the direct track from Jervis Bay.

After an extensive search, the aircraft wreckage was located in mountainous terrain, 34 km south-east of Benalla. The impact and an intense post-impact fire destroyed the aircraft, including its instruments and GPS navigation equipment. On-site examination found that the aircraft had collided with trees when in a wings-level, climbing attitude and with the landing gear and flaps extended for a landing approach.

Examination of the aircraft's maintenance records has not identified any mechanical or systems defect that might have influenced the circumstances of the accident.

The investigation is examining a number of issues of possible safety significance. The ATSB expects to release an Interim Factual report by February 2005.

Copies of the Report Aviation Safety Investigation Report 200402797

Failure to keep a proper lookout by either vessel has been identified as the immediate cause of the ninth collision in five years between a fishing vessel and a ship off the Australian coast.

In the early hours of 21 August 2003, the fishing vessel Jenabar collided with the bulk carrier Lancelot off Diamond Head on the New South Wales coast. The report on the collision by the Australian Transport Safety Bureau (ATSB) also identifies that over-reliance on board Lancelot on information from the automatic radar plotting aid contributed to the collision.

On this occasion nobody was hurt, though the fishing boat sustained damage and had to return to Forster, where it arrived safely.

The collision occurred while Jenabar, in company with three other fishing vessels, was heading for fishing grounds to the north of Forster. On board Jenabar, the deckhand on watch was seated at a table in the wheelhouse.

The mate on the bulk carrier, which was southbound for Newcastle, was using the automatic radar plotting aid (ARPA). Despite indications from the ARPA that the fishing vessels were passing clear, they were in fact on collision or near-collision courses.

After the collision, the ship turned around to assist the fishing vessel but, on learning that assistance was not required, resumed its passage to Newcastle.

Since July 1999, the ATSB has released nine reports on similar collisions. It has also released two safety bulletins for crews of ships and fishing vessels with advice on the avoidance of collisions. The reports and safety bulletins have emphasised the need for a proper lookout and the limitations of radar and the report on this latest collision concludes that:

• The mate on Lancelot did not check the compass bearings of the approaching vessels to assess the risk of collision;
• The moderate seas and the size and construction of Jenabar would have had an adverse effect on its radar detectability; and,
• The deckhand on watch on Jenabar at the time of the collision was not keeping an adequate or effective lookout.

The report's recommendations include the need for:

• Vessels to keep a proper lookout at all times;
• The National Marine Safety Committee (NMSC) and State and Territory marine authorities to review the minimum qualifications for watchkeepers on fishing vessels;
• NMSC and State and Territory marine authorities to ensure that guidance on procedures for watchkeeping and safety of navigation applies to all vessels.

Copies of the report can be downloaded from the website, or obtained from the ATSB by telephoning (02) 6274 6478 or 1800 020 616.

The ATSB has found that a stabilised approach and a ground proximity warning system would have reduced the risk of the controlled flight into terrain (CFIT) accident that occurred at Coffs Harbour on 15 May 2003.

The final Australian Transport Safety Bureau (ATSB) investigation report was released today. According to the ATSB, the King Air aircraft hit the sea or a reef near the Coffs Harbour boat harbour during an instrument approach in heavy rain and poor visibility. Although the aircraft was damaged and the left main landing gear was broken off, the aircraft kept flying and just cleared a nearby restaurant.

The pilot was able to carry out an emergency landing at Coffs Harbour and there were no injuries.

The reason the pilot allowed the aircraft to descend below the minimum descent altitude (MDA) for the approach when the runway was not in sight was unclear. However, the ATSB investigators believe there were a number of factors that contributed to the inadvertent descent including high pilot workload related to hand flying a steep descent in bad weather and the absence of adequate defences against CFIT. The aircraft's rate of descent may also have been accelerated by downdrafts associated with the heavy rain.

Defences against CFIT include adequate standard operating procedures, stabilised approach criteria, missed approach criteria and ground proximity warning systems.

Copies of the report (Aviation Safety Investigation Report 200302172) can be downloaded from the website.

The ATSB has found that the fatal accident at Camden aerodrome on 7 February last year was the result of a simulated engine failure during a flight test at night that was initiated at too low a height to ensure safety.

The Beech Duchess twin engine aircraft, VH-JWX, crashed shortly after takeoff, seriously injuring the trainee pilot and fatally injuring the pilot in command who was an Approved Testing Officer (ATO) authorised by the regulator.

The aircraft was recovering after the engine failure simulation when the right wingtip collided with a tree. Shortly after, the aircraft impacted the ground.

While the cabin area remained intact during the accident sequence, an intense fire started and both occupants were seriously burnt as they escaped and the ATO did not survive his injuries.

The engine-failure simulation was initiated from a point where the crew could not be confident that they would clear all obstacles. As it was dark, they could not see any obstacles that needed avoiding.

Guidance was provided in aeronautical information publications recommending against low-level asymmetric operations at night below 1500 feet, however such operations were not prohibited.

The Civil Aviation Safety Authority (CASA) has advised ATSB investigators that new regulations are presently being drafted which will enhance the consistency of flight test operations for the future.

ATSB report Aviation Safety Investigation Report 200300224 can be downloaded from the website, or obtained from the ATSB by telephoning 1800 020 616.

A media briefing to discuss the circumstances of the 28 July 2004 Piper Cheyenne, VH-TNP accident near Benalla, Victoria will be held at Myrrhee Hall off Boggy Creek Road at 4.00pm today, 29 July 2004.

The Investigator in Change, Alex Hood, will discuss factual events as are known to the investigation team at this point in time.

With the exception of this media conference all media contact will continue to be addressed by the Bureau's central office, details below.

The Australian Transport Safety Bureau has dispatched a team of four investigators and support staff to determine the circumstances surrounding the tragic accident near Benalla, Victoria, on 28 July 2004.

The factual circumstances to hand are that at about 11 am on the 28th of July, a Piper Cheyenne, VH-TNP, en-route Bankstown (NSW) to Benalla (Victoria) with six people on board disappeared from radar about 33km south-east of Wangaratta, where weather conditions were low cloud and rain. Airservices Australia will be providing these radar and air traffic control tapes to the Bureau to aid in the investigation.

The Australian Search and Rescue organisation, AusSAR undertook a major search of the area and while hampered by extreme weather conditions located the aircraft wreckage at about 5.50pm. Sadly, all six occupants of the aircraft perished in the accident and our sympathies are with family and friends of the victims.

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

A media conference will be held in the area today, the precise location and time to be advised, where the Investigator in Charge will outline the factual information we have to hand at that point in time. Until further notice all media contact will be with the Bureau's central office, details below.

The failure of officers to use modern navigation bridge management principles was the major factor in the grounding of the Bahamas registered passenger ship Astor during the ship's departure from Townsville at around 7 pm on 26 February 2004, according to an Australian Transport Safety Bureau (ATSB) investigation report released today.

The ATSB report into the Astor grounding released today states that the ship grounded on its port side as it was turning from Townsville harbour into Platypus Channel. The ship heeled about three degrees to starboard and, after about three minutes, slid clear of the bank without assistance and continued out of the channel. No injuries or pollution resulted from the grounding.

The report concludes that, after the Astor left its berth, the ship's master did not accept the advice of the Townsville harbour pilot on board. By failing to take the pilot's advice, the master incorrectly positioned the ship for a turn to starboard into Platypus Channel, part of the approach channel to the port, resulting in the ship running aground during the turn. The report also concludes that the pilot was unable to understand the Ukrainian language of the officers and crew on the navigation bridge.

The ship's managers stated six days after the grounding that an onboard investigation had found a steering malfunction caused the grounding. This was the first time a steering gear malfunction had been mentioned by ship's staff or shore management to any Australian authorities or organisations.

The ATSB carried out a thorough examination of the ship's steering system and consulted with the manufacturers of the steering equipment. The investigation has been unable to determine the degree, if any, to which the reported malfunction contributed to the grounding.

The investigation was also complicated by the fact that information from the Astor's 'black box' data recorder was not backed up immediately after the grounding and by the fact that company procedures were not followed with respect to the keeping of bridge records.

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

A study by the ATSB has shown that just under half of the general aviation fatal accidents in the ten year period between 1991 and 2000 were Uncontrolled Flight Into Terrain (UFIT) accidents, where an intact aircraft collided with a stationary obstacle or terrain after an in-flight loss of control had occurred.

In more than half of the UFIT fatal accidents an event that was either not averted, or not managed appropriately by the pilot, or was not within the pilot's control, preceded the loss of control. However, in the vast majority of UFIT fatal accidents that occurred during low-level flying operations, there was no precipitating event and the loss of control situation could not be corrected before the impact, given the aircraft's height above the ground when the loss of control occurred.

Controlled Flight Into Terrain (CFIT) fatal accidents (where an aircraft collided with a stationary obstacle or terrain during powered, controlled flight, taking the pilot unawares) was the second most common accident type (30 per cent of fatal accidents).

The majority of CFIT fatal accidents occurred during low-level flying operations, when the visibility was adequate: most of these accidents were wirestrikes. Pilots involved in fatal CFIT accidents who were flying unnecessarily low accounted for a quarter of all CFITs. They also accounted for 42 percent of all CFITs during low-level flying operations. The large majority of CFIT fatal accidents that happened when the pilot did not plan to conduct low flying operations, occurred when the pilot was not able to see the outside environment. This happened under visual flight rules or instrument flight rules, and was due to either poor visibility or darkness.

Research also showed that general aviation occurrences between 1700 and 2059 were 1.6 times more likely to be fatal than during other times of the day. Furthermore, occurrences involving private/business operations were 1.9 times more likely to be fatal over the weekend than during the working week.

Depending on the scale of feedback about this report, the ATSB will consider releasing a supplementary section of this report that addresses issues and questions that have been raised.

The ATSB has released a major accident report on behalf of the Government of East Timor into the fatal accident on 31 January 2003 which resulted in six fatalities.

The ATSB found that the accident occurred when a large Russian-made Ilyushin IL-76 cargo jet aircraft crashed at Baucau, East Timor in bad weather after impacting terrain while attempting to land.

On behalf of the East Timor Government the ATSB, with the assistance of Australian Defence (DFS-ADF and DSTO) officers and the Moscow-based Commonwealth of Independent States Interstate Aviation Committee, investigated the accident.

The final investigation report was released following a briefing provided late yesterday by the ATSB and the Australian Ambassador to the Prime Minister and other members of the Timor-Leste Ministerial Council.

While it is not the object of an ATSB investigation to apportion blame or liability, the investigation found in addition to the bad weather, the aircraft crew didn't have accurate aerodrome charts and there was poor crew resource management (CRM) in the cockpit.

The aircraft descended below the lowest safe altitude for the sector and impacted terrain well short of the runway in a controlled flight into terrain (CFIT) accident which is a preventable but common cause of major accidents around the world.

Safety recommendations from the report to avoid CFIT include better use of available technology and equipment, implementing standard operating procedures, and improving collegiate crew decision-making, risk assessment and management.

The ATSB's aviation safety survey of commercial pilots, Common Flying Errors, has revealed that, violations of standard operating procedures were more prevalent in general aviation and were involved in 11.8% of all events.

The survey asked pilots to identify the main factors contributing to errors and the defences they used to recover. Most errors occurred en route, distantly followed by flight preparation errors.

All categories of pilot experienced errors while executing procedures en route, such as not completing their landing checklist, and misprocessing information from their operational environment, such as an unexpected decline in weather conditions. Most identified errors involving mishandling as a concern, such as heavy landing; misconfiguration, such as landing with the flap setting one less than configured for; and misprocessing navigational information, such as an incorrect GPS identifier.

The contributing factor identified by all categories of pilot as enhancing the likelihood of error was lack of pilot experience. Failing to complete procedures, such as not cross-checking figures, and experiencing problems with systems equipment, such as frequency congestion, also exacerbated errors in most categories.

Operational personnel across all flight categories indicated that there was frequently no defence present to protect against the error. When a defence was available, pilot skills and implementing procedures predominantly enhanced error recovery. Very few pilot responses indicated that a defence had been employed after the event to reduce the potential of recurrence.

Overall:

• violation of standard operating procedures was involved in 11.8% of events;
• wilfully risky activities were present in 3.2% of error events;
• in 2.1% of reported events an accident occurred;
• 9.1% of respondents were involved in a concern relating to a mid-air collision, most of which involved no warning (unalerted confliction 6.1%).

Some caution is required when interpreting results because considerable amounts of data were missing. The survey conveys the opinion of pilots and not the opinion of the ATSB. Results do not suggest that aviation is more at risk of error than other transport activities.