After allowing for activity levels, ATSB research indicates that Robinson R22 helicopters have a similar safety profile to other comparable helicopters.

This study was prompted by increasing concerns about light utility helicopter safety in Australia. Light utility helicopters make up half the registered fleet yet were involved in 72 per cent of all helicopter accidents between 1985 and 2003.

The report compared accident involvement and accident rates of four helicopter models; Robinson R22, Bell/Agusta/Kawasaki 47G, Hughes/Schweizer 269 and Hiller UH-12E.

The Robinson R22 was involved in more accidents and fatal accidents than any other light utility helicopter but also flew more hours than the other three helicopters whose risk profiles were studied. The Bell/Agusta/Kawasaki 47G model had the next highest involvement in accidents followed by the Hughes/Schweizer 269 and then the Hiller UH-12E. However, when comparing the relative safety of different aircraft models the best available indicator is the accident rate per hours flown.

The overall trend in accident involvement and accident rate per hours flown has improved since 1990 for all the light utility helicopter models. The accident rate per hours flown for the Robinson R22 model indicates that up to 2002 this helicopter's record was as safe, if not safer, than other similar helicopter models. Since 2002, the Bell/Agusta/Kawasaki 47G model has had the lowest accident rate per hours flown.

For the combined period, 1990-2002, the Robinson R22 had the lowest accident rate per hours flown of 1.8 accidents per 10,000 flying hours compared with the next lowest rate for the Bell/Agusta/Kawasaki 47G of 3.1 accidents per 10,000 flying hours.

As of 20 May 2004, seafarers will be able to make their safety concerns known under a new AUSTRALIAN GOVERNMENT safety initiative.

The Australian Transport Safety Bureau (ATSB) is introducing a Confidential Marine Reporting Scheme (CMRS) to improve safety in Australian waters by preventing or reducing the risks of marine accidents.

The marine industry, which was widely consulted on the scheme, has welcomed its introduction.

Seafarers and others connected with the marine industry will now be able to report, confidentially, any unsafe conditions, practices or procedures on ships. The scheme is also intended for use, for instance, by a passenger on a ship or a person ashore who observes and wishes to report a marine safety issue.

Under the Transport Safety Investigation Act 2003, the ATSB investigates and reports on marine accidents. Now, under the Navigation (Confidential Marine Reporting Scheme) Regulations 2004, the ATSB will accept and act, where appropriate, on confidential marine reports.

All reports will be processed to ensure that the identities of reporters are kept confidential.

The scheme encourages the reporting of safety issues by ship's crews and people concerned for maritime safety. However, it may not be used by masters and others who have an obligation, under other legislation, to report accidents where they were involved. Neither is the scheme intended for reporting industrial relations issues or unlawful interference with a ship.

Reports will be accepted by phone, email, fax or on-line or by using the ATSB's confidential marine reporting form. Any reference to, or any information that might identify, a reporter will be removed to 'de-identify' each report. Reports will then be assessed by experienced mariners who will determine what action is required. The de-identified information will be entered into a secure database to enable the reports to be analysed for safety information or trends.

The information from confidential reports may be forwarded by the ATSB to the Australian Maritime Safety Authority. The information may also be used to issue information briefs or alert bulletins to the maritime community. The ATSB will publish reviews of information from confidential reports and will assess the effectiveness of the scheme with a committee established for that purpose.

A new ATSB research investigation report analyses the 37 midair collisions in Australia from 1961 to 2003. None involved scheduled passenger (RPT) aircraft and over three quarters involved general aviation aircraft that collided in good weather in or near the circuit area of an airport.

Of the 78% of midair collisions in circuit areas, nearly half occurred on the final leg of the circuit or on the base-to-final turn. Most midair collisions occurred between aircraft converging on similar courses, or flying in the same direction. A range of contributing factors were evident, but there were no dominant factors.

Nineteen of the collisions resulted in fatalities. A high proportion of the midair collisions occurred at the five major Australian general aviation airports; namely Archerfield, Bankstown, Jandakot, Moorabbin and Parafield.

The rate of midair collisions between 1981 and 2003 was similar to the rate in the US, however the US had a higher proportion of midair collisions away from the circuit area. This is consistent with the greater traffic density and general aviation flying activity in the US.

The characteristics of the contributing factors involved in Australian midair collisions were generally similar to those observed in other countries, such as the US, France and Canada.

The ATSB is seeking comment on its Aviation Research Discussion Paper by 31 May 2004, with a view to incorporating supported suggestions for improvement.

An ATSB interim factual investigation report has found that the airspace incident near Brisbane on 7 April involving a B737 and a Lancair aircraft was not an 'airprox' event.

In this incident, the two aircraft passed with 600 feet vertical and 0.4NM (about 1 km) lateral separation in new Class E airspace, but were not in danger of collision.

Unlike the Launceston airprox last Christmas Eve, in this incident the smaller Lancair aircraft was on air traffic control radar and in communication with controllers and the B737 aircraft had initiated a change of flightpath before receiving two TCAS alerts.

The Lancair pilot informed the controller that he had the B737 in sight. While the B737 crew were unable to see the Lancair, they noted its presence on TCAS prior to the TCAS traffic advisory (TA) and resolution advisory (RA) alerts and they also received three reports of traffic from the air traffic controller.

The ATSB's interim factual report states that the Boeing 737-7BX, operating under the instrument flight rules (IFR), was en route from Townsville and descending for a landing at Brisbane, while the Neico Lancair IV-P, operating under visual flight rules (VFR), was en route from Maroochydore to St George, on climb to flight level (FL)165.

As the B737 was approaching FL 157, the crew noted the Lancair via the aircraft traffic alert and collision avoidance system (TCAS). At that point the crew reduced the rate of descent. Thirty seconds later they received a TCAS TA. Recorded data from the B737's flight data recorder indicated that the crew levelled the B737 at FL 153, and then climbed to FL 154 and commenced a right turn away from the Lancair.

About 22 seconds later, the crew received a TCAS RA instructing them to climb. They subsequently climbed the B737 to FL 166 and continued the right turn to about 15 degrees right of track. Recorded radar data indicated that the Lancair passed behind and below the B737. The minimum distance between the two aircraft was about 600 feet vertically and 0.4 NM laterally.

Information obtained from the crews of both aircraft, the Airservices ATS controller, recorded flight data from the B737, ATS audio recordings and radar data, is consistent and indicates that the crews of both aircraft and the ATS controller complied with the published procedures for Class E airspace under NAS 2b.

ATSB analysis indicates no adverse safety trend since NAS stage 2b was introduced on 27 November 2003 based on the ATSB's preliminary review of its aviation safety occurrence database, including an examination of TCAS resolution advisory alerts.

Because of the significance of NAS airspace changes and public debate over the safety of their implementation, the ATSB has reviewed and categorised NAS-related occurrences and undertaken a comparative analysis of TCAS resolution advisory (RA) alerts in the 140 days from 27 November 2003 with 140 days a year earlier.

There were 37 RAs after NAS 2b was introduced and 38 RAs in the same period a year earlier - accordingly, no trend is apparent. One of the RAs in each period was indicative of a more serious safety situation. A second RA on 7 April 2004 in the latter period was still under investigation.

The one serious RA occurrence after NAS 2b was introduced occurred at Launceston on 24 December 2003. The ATSB assessed this as an 'airprox' incident and noted that: While a single occurrence does not provide the basis for a major change to the US-based NAS, which is yet to be fully implemented, the circumstances of this serious incident are indicative of a need for further review and analysis by CASA and Airservices Australia in consultation with industry. Such reviews have been initiated.

In the pre-NAS 2b period, the one more serious RA occurrence was associated with a 'breakdown in separation' in Class C airspace linked to an air traffic control oversight. At their closest, the two jet aircraft involved came within 1200 feet vertically and 2.5 NM laterally.

The ATSB is seeking comment on its Aviation Research Discussion Paper by 21 May 2004 with a view to incorporating suggestions for improvement in the context of a proposed publication in July containing six months of post-NAS 2b occurrence data.

Today the ATSB is issuing a preliminary report of the investigation into the accident involving an Aero Commander 500-S, registered VH-LST.

The accident occurred on 19 February 2004, at about 1700 Eastern Summer Time (ESuT), approximately 58km NNW of Hobart Aerodrome.

The report provides factual information as at 29 March 2004.

The aircraft departed Hobart Airport for Devonport, Tasmania at about 1643 ESuT. The pilot made several radio transmissions, the last indicating that the aircraft had left 4,500 ft on climb to a cruising altitude of 8,500 ft.

The wreckage pattern indicates that the aircraft sustained a structural failure resulting in airframe disruption while airborne. The reason for the structural failure is still under investigation.

The investigation is continuing and is examining several aspects in relation to the accident, including the aircraft structure, maintenance, flight operations, air traffic control, meteorological conditions and human performance.

The ATSB has found that the Hamilton Island accident in which six people died was the result of a low altitude stall. The tragedy provides an important opportunity to highlight some dangers to flight safety including post-alcohol impairment, cannabis, and fatigue.

At about 5pm on 26 September 2002, Piper Cherokee Six registration VH-MAR crashed shortly after take-off from runway 14 at Hamilton Island heading for the neighbouring Lindeman Island. The pilot and five passengers were fatally injured, and the aircraft was destroyed by impact forces and the post-impact fire.

The final ATSB investigation report has found that the aircraft's engine began operating abnormally soon after take-off, the pilot initiated a steepening right turn at low level, and the aircraft stalled at a height from which the pilot was unable to effect recovery.

The reasons for the engine problems and for why the pilot undertook such a turn could not be conclusively established due to a lack of evidence. It is possible the steepening right turn over land was linked to inadequate training and/or pilot physiological factors.

Previous pilot use of cannabis was evident from toxicology tests, and he had consumed alcohol the night before, had taken panadeine, and had less than 7 hours sleep, but there was insufficient evidence to definitely link these factors to the accident. But the possible adverse effects on pilot performance of fatigue, recent cannabis use, and post-alcohol impairment linked to 'Coriolis' and 'G-excess' phenomena could not be discounted.

In the interests of future safety the ATSB is also releasing aviation research papers on the effects of alcohol and cannabis on pilot performance and other flight safety. While alcohol's effects are relatively well known, research on cannabis is mainly based on 10mg THC doses in reefers typical from the 1960s rather than the 150mg more typical today and the safety effects of smoking cannabis may continue well beyond 24 hours.

The ATSB has issued three recommendations which address the potential use of alcohol and drugs by aviation personnel where there is a safety risk to the travelling public.

The ATSB has also issued to CASA a recommendation on Air Operator Certificate Safety Trend Indicator surveillance methodology, and safety advisory notices relating to pilot manipulation of the Cherokee Six fuel selector, and to development by operators of pilot induction training programs that reflect particular operational risks.

The operator has initiated a number of safety actions including pilot retraining covering engine failure over water, fatigue and work schedule management, use of full runway length for all take-offs, and amendment of the flight operations manual where required.

The reports are available from the website Piper Aircraft Corp PA-32-300, VH-MAR Hamilton Island, Aero., Qld

The ATSB has found that the Moorabbin fatal accident was mainly the result of a lack of pilot situational awareness related to different aircraft night training circuit sizes.

At about 6.40pm on 29 July 2002, two Cessna 172R aircraft collided while on approach to runway 17 left at Moorabbin airport. The two aircraft became entangled, with aircraft VH-CNW on top of VH-EUH and impacted the runway and came to rest after sliding a short distance along the runway surface. The pilot of VH-CNW was fatally injured.

The Moorabbin Air Traffic Control Tower was not in operation at the time of the accident and mandatory broadcast zone (MBZ) procedures were in use that required pilots to see-and-avoid other aircraft and to make various mandatory radio broadcasts.

Six aircraft were operating in the MBZ at the time of the accident and the investigation identified the following significant factors:

• the different circuit dimensions negated the natural spacing provided by the difference in take-off times, even though both EUH and CNW were the same aircraft type and were operating in the circuit at similar speeds. Radar data indicated that the pilots of EUH conducted a wider circuit than the pilot of CNW. While the EUH circuit took about 7 minutes the CNW circuit took about 4.5 minutes. Both were considered within the normal range and not contrary to procedures.
• the pilots involved in the accident did not see the other accident aircraft in sufficient time to enable either of them to avoid the collision.
• the required broadcasts and a discretionary broadcast made by the pilots did not sufficiently assist their situational awareness.

Subsequent to the accident, the flying school operator instituted changed procedures that require company instructors to append their perceived position in the landing sequence to the broadcast they make at the start of the base leg of the aerodrome circuit.

The investigation found deficiencies in the risk management process associated with the reduction in the Moorabbin airport air traffic control tower hours of operation. Identified deficiencies have since been addressed by Airservices Australia.

The investigation could not determine whether the reduction in tower hours after 21 December 1998 contributed to the accident. In September 2002, Airservices Australia approved a plan for an ongoing airport movement review outside tower hours for air traffic control towers that were not open 24 hours per day, which included Moorabbin tower, to monitor the need for an air traffic control service. To date the review has not indicated a need for an increase in control tower hours at Moorabbin.

A final ATSB investigation report into a serious incident involving a Saab passenger flight in June 2002 has found that pilots lost control because of low airspeed, airframe icing and the operation of the aircraft autopilot system, and that they did not receive a prior stall warning.

As a result of this serious incident and an ATSB report released in May 2001 into a similar serious incident, the ATSB has made further safety recommendations to operators, to Saab, and to CASA.

On the evening of 28 June 2002, a Saab 340B, VH-OLM, operating as a regular public transport service from Sydney to Bathurst experienced an in-flight loss off control after it levelled out at its minimum descent altitude of 3810 feet.

The pilots inadvertently allowed the aircraft's power to remain at about 17 per cent when it should have been over 50 per cent and the stall speed was higher than normal because of airframe icing.

The aircraft initially rolled to the left and pitched down without warning and during the recovery from the first stall, the aircraft rolled to the right and descended to 112 feet before altitude was recovered.

The investigation found that it is possible for the aircraft to stall prior to the activation of the stall warning system if the aircraft has accumulated ice on the wings.

The pilots did not appreciate the seriousness of the incident until after it was reported to the ATSB by passengers and the ATSB had investigated the circumstances.

The investigation, classed as a serious incident report, identified a number of other occurrences involving Saab 340 aircraft stalling where little or no stall warning had been provided to flight crew while operating in icing conditions.

As a result of a 1994 fatal accident involving airframe icing to an ATR-72 at Roselawn, the US FAA issued an airworthiness directive, which applied to US Saab 340s, requiring that flight manuals warn that autopilot operations may mask problems in severe icing conditions. For Saab 340s in Canada, an ice stall warning protection option is fitted to aircraft.

The ATSB believes the Saab 340's defences should be enhanced to protect against situations of human error such as failing to take early action on power and speed and/or failing to notice ice accretion.

The ATSB has recommended that as a matter of priority Saab modify the stall warning system on the worldwide fleet to give sufficient warning of an impending stall during icing conditions.

The ATSB urges operators of the aircraft type to carefully note the circumstances of this recent serious incident as well as the previous Australian serious incident and international accidents and incidents and alert and train their crews accordingly.

The ATSB's final investigation report has found that a Boeing 737 passenger aircraft that overran the runway in Darwin in June 2002 did so because of a high approach speed, an inaccurate and unstabilised approach, and poor crew resource management.

Significant safety action has been taken by the operator to address the problems found and to improve training and safety systems to seek to ensure it doesn't happen again.

At about 1135pm on 11 June 2002, Boeing 737-800 registered VH-VOE touched down an estimated 1016 metres from the departure end of Runway 29 at Darwin, overran the runway and came to a stop about 44m into the 90m runway end safety area.

There were no injuries among the 92 passengers and 7 crew when the aircraft crossed the end of the runway at 35-40 knots groundspeed, and the aircraft was undamaged.

The investigation found that the pilot in command continued with an unstabilised approach and did not go around in accordance with company operating procedures. The copilot did not announce that the approach was unstable and call for a go around. A high approach speed led to a long landing and overrun situation.

Runway overruns and excursions are prominent in accidents and serious incidents involving passenger jets and typically involve long and/or fast landings.

Other factors in the Darwin incident included that the non-precision approach was flown at night in circumstances conducive to visual illusions; a displaced runway threshold limited the landing distance available; and that the relatively new operator had at the time an underdeveloped crew landing risk assessment and a safety management system that did not incorporate recommended flight data monitoring programs.

As part the operator's maturation process, it has developed a number of measures that are being implemented over the short, medium and longer terms to improve the training of crews, and the capability of the operators safety management system