The ATSB supports safety recommendations the SA Coroner has made today that reinforce those by the ATSB, but disagrees with some of the Coroner's key conclusions.

The ATSB formally re-opened its investigation in November last year after possible significant new evidence about a potential manufacturing defect in the left engine crankshaft became available from the US engine manufacturer (Textron Lycoming)

- the ATSB has since re-tested the crankshaft, including using destructive testing open to non-Bureau witnesses and the input of external laboratories, and found no problems with the steel that could have led to it fracturing under normal operating conditions;
- in contrast to the Coroner's conclusion, this confirmed the ATSB report findings.

The ATSB does not agree with the SA Coroner that the pilot of VH-MZK would have allowed, ahead of any stressful situation, his right engine to overheat to the point of melting a hole in a piston and then be unlucky enough that a deep-seated long-term problem in the left engine crankshaft would have suddenly caused that engine to fail
- the ATSB continues to believe that the left engine failed first and then the right engine overheated when power was boosted in response, when seeking to reach Whyalla;
- as the ATSB told media when releasing its report on 19 December 2001, it is not appropriate to blame the young pilot in this scenario and the ATSB did not do so.

The ATSB report also did not criticise Whyalla Airlines for its fuel leaning settings in climb, finding that they were in accordance with the aircraft manufacturer's guidelines
- the ATSB continues (since October 2000) to urge industry to use conservative (rich) fuel climb settings in Piper Chieftains to minimise the possibility of engine damage.

The December 2001 ATSB investigation report was released after a major 18 month investigation and was based on the evidence available at that time
- there were no survivors or any aircraft flight data or cockpit voice recordings to assist the ATSB with the very complex investigation;
- the recommendations that the ATSB made in 2000 and 2001 to improve future safety have been widely regarded, including by the US Federal Aviation Administration.

The ATSB cooperated fully with the South Australian State Coroner's inquiry in the 18 months since the Bureau's report was released but found the inquest unduly adversarial
- parties seeking US civil damages money used the inquest to attack the ATSBs report into what are very complex issues, and this was supported by the Coroner's assistants;
- the ATSB has no financial or 'blame' agenda and is only interested in future safety;
- in hindsight any complex report can be improved and the ATSB's is no exception.

The Executive Director of the ATSB, Mr Kym Bills, has today written to the SA Coroner seeking any significant material that he may have relied upon that the ATSB has not seen. The Bureau will carefully review any new material provided before publicly releasing a supplementary report to close its re-opened investigation.

Presentation given to Waypoint 2007 on Investigation and data issues.

Speech delivered to Asia-Pacific Coroners' Conference, Hobart, Tasmania on ATSB fatality investigations in Australia and the Asia Pacific by Mr Kym Bills, Executive Director, Australian Transport Safety Bureau.

Overview

• Australia has a very safe transport system in international terms across all modes
• However, major accidents are low probability, high consequence events and we can never afford to be complacent
• Human factors associated with well-known human performance continue to dominate
• Systemic investigations remain crucial but pro-active reporting and data analysis also provide for evidence-based risk reduction.

Spoken by Mr Kym Bills, Executive Director, Australian Transport Safety Bureau 23 July 2007

Presentation given by Mr Kym Bills,
Executive Director
Australian Transport Safety Bureau
Department of Transport and Regional Services

Speech presented 7 Aug 2006

Rail 2007, Sydney NSW, 3 April 2007

The increasing cooperation between Australian transport safety investigators and their counterparts from the Commonwealth of Independent States (CIS), has been recognised by the signing of a Memorandum of Understanding this morning.

The Memorandum was signed by the Australian Transport Safety Bureau (ATSB) and the Interstate Aviation Committee (IAC), representing 12 Independent States: Azerbaidjan, Armenia, Belorus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russian Federation, Tajikistan, Turkmena, Uzbekistan and Ukraine.

This agreement sets out protocols for the sharing of expertise and experience relating to investigations, with the sole objective of improving the safety of air transport, ATSB Executive Director, Mr Kym Bills, said.

We are working closely with the IAC on the investigation into the crash of a Russian aircraft near Cakung Airport, Baucau, East Timor, on January 31 this year.

The IAC represents the country of manufacture and design of the aircraft involved.

IAC investigators are assisting with information about the aircraft as well as flight recorder replay and analysis.

The ATSB and IAC investigate accidents and incidents so that the industry can prevent such occurrences from happening again as enshrined in Annex 13 to the Convention on International Civil Aviation, we do not investigate with a view to blame or liability.

Both Australia and the Commonwealth of Independent States are also members of the International Transport Safety Association (ITSA), the International Society of Air Safety Investigators (ISASI) and the Flight Safety Foundation (FSF).

In the Memorandum, the ATSB and IAC have agreed to:

• Provide assistance, in the form of investigation facilities and equipment, as resources permit. This assistance may include expertise in the fields of air traffic services, engineering, operations, flight recorders, human performance and management organisation.
• Appoint investigators as observers or participants in investigations, with a view to improving understanding of each others investigation requirements and procedures.

The Memorandum applies to:

• Aircraft, operated by the States-signatories, in the territory of Australia; and
• Australian-operated aircraft in the territory of the States-signatories.

Mr Bills said the Memorandum would serve to build the ATSBs experience and offer valuable opportunities to share information and expertise.

Speech given to International Transport Safety Association by Kym Bills Executive Director, Australian Transport Safety Bureau

15 May 2007

Speech delivered to Safeskies 07 Conference in Canberra, ACT on The ATSB perspective on Safety Management Systems in Australia by Mr Kym Bills, Executive Director, Australian Transport Safety Bureau.