On 1 March 2003, the Government of Timor Leste released its Preliminary Report into the fatal aircraft accident near Baucau on 31 January 2003.

At the request of the Government of Timor Leste, the Australian Transport Safety Bureau (ATSB) has today posted this preliminary report on its web site.

The Ilyushin IL-76TD aircraft impacted the ground near Cakung Airport, Baucau, during a landing approach. All six crew on board were fatally injured in the crash.

ATSB Deputy Director, Air Safety, Alan Stray said the investigation was continuing.

At the request of the Government of Timor Leste, the ATSB appointed an Accredited Representative to the investigation, who is assisted by investigators from the ATSB, the Directorate of Flying Safety Australian Defence Force and the Defence Science and Technology Organisation, he said.

The investigators are working to identify what factors led to this accident and loss of life and what can be done to prevent it from happening again.

During the preliminary phase of the investigation, we have identified several recommendations for safety actions the Government of Timor-Leste and the United Nations could take to improve flight safety.

The recommendations to the Government of Timor Leste include:

• The development of instrument approach and aerodrome charts for Baucau, Timor Leste;
• That the government review the provision of air traffic services and facilities to aircraft operations into Baucau.

We have also recommended that United Nations Air Operations assist the Government of Timor Leste to develop and promulgate approved instrument approach and aerodrome charts for Baucau, Mr Stray said.

The ATSB has found that the tanker, Dampier Spirit, did not have sufficient speed to safely evade a cyclone that was approaching the coast of Western Australia after its mooring hawser failed on 6 April 2006.

Dampier Spirit is a floating storage and offloading tanker for the Stag oil platform near Dampier, Western Australia, that is usually attached to a mooring buoy one nautical mile from the platform. At the time of the incident, the 106 668 tonne tanker had a partial load of about 12 100 tonnes of crude oil on board.

At 0958 on 6 April 2006, the ship was forced to put to sea as Cyclone Hubert approached when the mooring hawser attaching the ship to the buoy failed under load. The ship's master had delayed making the decision to disconnect from the buoy when the cyclone was declared, a delay which effectively reduced the time available to navigate the ship safely out of the cyclone's path.

Once disconnected from the buoy, the ship had difficulty making sufficient headway in the strong winds and heavy seas produced by the cyclone because its speed was limited by 'slow steaming' fuel injector nozzles that had been fitted in the main engine and by the build-up of marine growth on the hull.

Dampier Spirit was tracking towards Tryal Rocks for over three hours until the wind eased at 0305 on 7 April, allowing the tanker to sail into safer water. If it had grounded on Tryal Rocks, its cargo of crude oil may have spilled into the sea, resulting in significant damage to the environmentally sensitive mangroves and turtle nesting grounds in the area.

The report also concludes that the company guidelines for disconnection from the CALM buoy did not provide unambiguous advice to the master, the mooring hawser had been weakened by its service conditions and the master did not adequately consider the time needed to safely avoid the cyclone when making the decision to disconnect and depart from the buoy.

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

Copies of the report can be downloaded from the ATSB's internet site at www.atsb.gov.au,

The ATSB has found that a fire on board the Singapore registered ship Java Sea on 24 May 2005 started when hot pressurised thermal oil, possibly in the form of a spray, came into contact with an un-lagged section of the thermal oil heater exhaust piping. The fire was further fuelled by the contents of oil storage tanks located near the seat of the fire.

The Australian Transport Safety Bureau investigation found that the fixed fire extinguishing system was ineffective in extinguishing the fire because the ship's crew could not close the funnel casing ventilation dampers; the diesel generator was not shut down before the system was activated; and the oil tank quick closing valves were not operated.

At about 0540 on 24 May, a fire started in the engine room of the general cargo ship Java Sea while it was berthed in Cairns. Initial attempts by the ship's crew to fight the fire using a fire hose were unsuccessful and the decision was made to operate the engine room Halon 1301 fixed fire extinguishing system.

The release of the Halon 1301 proved ineffective. The fire was eventually extinguished by the Queensland Fire Service, using high expansion foam injected through a hole cut in the base of the funnel at poop deck level, directly above the seat of the fire.

There were no serious injuries as a result of the fire. However, the engine room and accommodation were significantly damaged by the fire and the associated fire fighting activities. The shiphad to be towed to Singapore for permanent repairs.

The report makes recommendations to ship owners, managers and masters with reference to closing arrangements for funnel casing ventilation openings and on board maintenance and emergency procedure manuals.

Copies of the report can be downloaded from the ATSB's internet site at www.atsb.gov.au

A media conference discussing the circumstances of the Bell 206B Jetranger Helicopter that crashed while undertaking water bombing operations during the Canberra Bush Fires of January 2003 will be held at 11.00 am today.

Who: Mr Alan Stray (Deputy Director, Air Safety Investigation)
When: 16 December 2003 (1100 ESuT)
Where: ATSB Headquarters (15 Mort Street, Canberra City)

The report will then be available on the website www.atsb.gov.au.

Note: Media are requested to assemble in the foyer at 15 Mort Street 15 minutes prior to the conference, from where they will be escorted to the conference venue.

The Australian Transport Safety Bureau will be conducting a media interview on the fatal aircraft accident at Bankstown Airport involving a Piper Seneca, VH-CTT.

Who: Ian Brokenshire (Investigator in Charge)
When: 12 November 2003, 1600 ESuT
Where: Near the Aviation Museum on Perimeter Rd, Bankstown Airport. Nearest major intersection is Milperra Rd / Henry Lawson Drive, turn off Henry Lawson Drive into Tower Rd. (Tower Rd leads to Perimeter Rd.)

The ATSB has found that there was no effective lookout being maintained on board either a fishing vessel or a bulk carrier when the two vessels collided off the South Australian coast on 23 April 2007, the latest in more than 50 such collisions investigated.

The Australian Transport Safety Bureau investigation again found that the fishing vessel was possibly difficult to detect, either visually or by radar, because of its timber construction, lack of a radar reflector, paint scheme and the prevailing weather conditions.

On the morning of 23 April, the Australian fishing vessel Peter Crombie was at anchor about 30 miles south of Robe, South Australia and the vessel's three crew members were below decks sleeping. The Panamanian registered bulk carrier Silky Ocean had sailed from Port Kembla, New South Wales, on 21 April, and was en-route to Ardrossan, South Australia.

The weather was fine with a partly cloudy sky and good visibility. There was a swell of about one metre from the east-southeast and seas of about 1.5 m. The wind was from the east-southeast at 12 to 18 knots.

At about 1150, Silky Ocean was on a course of 311(T) when it collided with Peter Crombie. Silky Ocean's bridge watchkeeper had not detected Peter Crombie either visually or on the ship's radar.

After the collision, Peter Crombie's skipper tried to contact the ship using his vessel's VHF radio. However, Silky Ocean's bridge watchkeeper did not acknowledge the call and made no attempt to communicate with the fishing vessel.

While Silky Ocean had sustained no damage as a result of the collision, Peter Crombie's hull had been damaged and the vessel was taking on water. Fortunately, the fishing vessel's bilge pumps were able to keep up with the ingress of water.

Peter Crombie's skipper notified the vessel's owners of the collision and then set a course for Robe. By 1700, the vessel was all fast alongside the wharf in Robe.

The ATSB is concerned that this type of collision continues to occur in Australian waters, sometimes leading to serious injury or fatality; and has issued five safety advisory notices with the aim of preventing similar incidents.

Copies of the report can be downloaded from the ATSB's internet site at www.atsb.gov.au

The Australian Transport Safety Bureau's supplementary investigation report into the fatal accident involving Whyalla Airlines Piper Chieftain registration VH-MZK on 31 May 2000 is expected to be tabled in the Senate before Question Time today. The report includes a detailed response to the South Australian State Coroner's critical findings on 24 July 2003.

After the tabling, ATSB Executive Director Kym Bills will address the media at 1.00pm today on key aspects of the Bureaus report.

Mr Bills will then be available for questions.

Who: ATSB Executive Director, Mr Kym Bills.
When: 1.00pm, Tuesday 28 October.
Where: 15 Mort Street, Canberra City.

The report will then be available on the website www.atsb.gov.au.

Note: Media are requested to assemble in the foyer at 15 Mort Street 15 minutes prior to the conference, from where they will be escorted to the conference venue.

The ATSB has found that a TransAdelaide passenger train passed a red stop signal last year, which placed it on a collision course with an interstate passenger train because of a combination of human error and sub-optimal procedures.

The Australian Transport Safety Bureau has today released its final report into the investigation of the factors that contributed to TransAdelaide passenger train H307 passing signal 161, at the end of a platform at Adelaide Railway Station, while it was displaying a red stop aspect, (an event commonly referred to as 'Signal Passed at Danger' or SPAD), on 28 March 2006.

The initial SPAD at signal 161 was typical of SPADs categorised as 'Starting Against Signal'. This type of SPAD typically occurs at railway stations where signals are positioned at the departure end of station platforms and the stationary train starts to move away from the platform before the signal displays a proceed indication. In this case, it placed train H307 on a collision course with the Indian Pacific which was on a crossing line 1.6 km from Adelaide station.

The investigation found that a conversation with station staff probably distracted the train driver's departure preparation. When scheduled to depart, a steady green light used by station staff to signal 'Right of Way' was a 'cue' which was in direct conflict with the red light displayed by signal 161. The investigation concluded that it was possible that the driver responded to the cue to proceed represented by the green Right of Way light and completed some minor tasks shortly after starting the journey but did not check the indication displayed by signal 161.

At the time of the incident, TransAdelaide's train control system did not provide a clear SPAD alarm. It is likely that an inexperienced controller, a period of high workload and the absence of a clear SPAD alarm contributed to a delay in train control personnel identifying that a SPAD had occurred.

The driver of train H307 believed that he had departed from the platform at Adelaide station under the correct signal indication and had been deliberately routed onto another track. The train had continued for two minutes and 610 m before the driver stopped the train. The driver's limited experience, his level of uncertainty regarding the unusual route and the absence of any information from the train controller to the contrary probably contributed to a delayed decision to stop and seek verification of the train's route.

The investigation noted that a new train control system was commissioned not long after the occurrence. The new system has audible and visual alarms to ensure that a similar SPAD should very quickly be recognised by train controllers. The investigation concluded that there were further opportunities for improvement. The ATSB recommended that TransAdelaide undertake further work to address safety issues relating to the SPAD investigation process and develop a clear understanding of SPAD causal factors such as potential underlying contributors to signal anticipation.

Copies of the report can be downloaded from the ATSB's internet site at www.atsb.gov.au

The ATSB has found that a leakage of dangerous goods on board the Liberian registered container ship Kota Pahlawan, off the coast of Australia, on 16 June 2006, occurred because the dangerous goods were not packaged properly.

The Australian Transport Safety Bureau investigation found that packaging deficiencies in similar past shipments of xanthates, the dangerous goods being shipped, were commonplace but not reported. It was also found that Kota Pahlawan transited the northern part of the Great Barrier Reef Inner Route before authorities made an appropriate risk assessment.

On the morning of 16 June, a foul odour was found to be coming from two containers of xanthates on board Kota Pahlawan. Xanthates, on contact with moisture, produce foul smelling, highly flammable and toxic carbon disulphide vapours and can spontaneously combust. Duct tape was used to seal the containers' doors and the master reported the incident to the ship's manager.

In the evening on 16 June, the master informed the ship's charterer that the packaging of the xanthates was not vapour-tight in accordance with international rules. He demanded that the containers be unloaded in Brisbane, the next port.

At 0411 on Sunday 18 June, a few hours before entering the Torres Strait, Kota Pahlawan's master reported the emission of odours to the Australian Maritime Safety Authority (AMSA). At 0720, the ship embarked a coastal pilot for its transit of the northern part of the Great Barrier Reef Inner Route.

At 0907 on Monday 19 June, AMSA issued a defect report for Kota Pahlawan and notified relevant areas within AMSA and Maritime Safety Queensland (MSQ). Both AMSA and MSQ then started collecting more information to make a risk assessment.

On 22 June, the ship berthed in Brisbane after an emergency was declared and exclusion zones were established. Emergency services attending the ship had confirmed a dangerous goods leakage. All eight xanthates containers on board the ship were unloaded and purged with nitrogen gas.

On 24 June, the emergency services declared the purged containers to be fit for transport and Kota Pahlawan's master was asked to reload them. The master agreed to reload the containers after AMSA provided its written acceptance.

On 25 June, Kota Pahlawan sailed from Brisbane with an emergency services scientific officer aboard to monitor the xanthates containers. The ship continued its voyage to Sydney, Bell Bay and Fremantle where the last of the containers were discharged on 6 July.

The ATSB report includes safety actions already taken and a number of recommendations and safety advisory notices with the aim of preventing similar incidents in the future.

Copies of the report can be downloaded from the ATSB's internet site at www.atsb.gov.au

An ATSB research report released today examines the problem of spatial disorientation.

Flying an aircraft is a challenging activity that exposes pilots to many potential hazards. One of the most significant of these is spatial disorientation. Spatial disorientation is a condition where the pilot is unable to correctly interpret aircraft attitude, altitude or airspeed in relation to the Earth. The resulting disorientation can lead to a loss of control of the aircraft.

Spatial disorientation is a very common problem. It is vitally important that pilots are aware that it can affect any pilot, any time, anywhere, in any aircraft, on any flight, depending on the prevailing circumstances. It has been estimated that the chance of a pilot experiencing spatial disorientation during their career is in the order of 90 to 100 per cent. In other words, if a pilot flies long enough as a career, or even a hobby, there is almost no chance that he/she will escape experiencing at least one episode of spatial disorientation.

The Australian Transport Safety Bureau (ATSB) commissioned aviation medicine specialist, Dr David Newman, to explore the various types of spatial disorientation in the aviation environment, and to suggest strategies for managing the risk associated with these events.

The ATSB report explains that the chances of a spatial disorientation event occurring in flight can be reduced by a series of simple preventive measures, many of which can be attended to before flight. These include flying when fit and well to do so, not flying under the influence of alcohol or medications, avoiding visual flight rules into instrument meteorological conditions, increasing awareness of spatial disorientation illusions and planning for their possible appearance at different stages of flight in the pre-flight planning process.

The ATSB report encourages pilots who have had a spatial disorientation event to share their experiences with their aviation colleagues, either informally, or through magazines, journals and web-based forums.

A more open approach to acknowledging and discussing spatial disorientation and its various causes will make a valuable contribution to a better understanding of this common human factor.

Copies of the report can be downloaded from the ATSB's internet site at www.atsb.gov.au