ATSB analysis shows that an increase in reported airline accident and incident data since 2001 is mainly due to industry expansion, and the rates of many types of occurrence have fallen.

The Australian Transport Safety Bureau research report released today covered more serious airline Immediately Reportable Matters in the 5 years from mid 2001 to mid 2006.

Despite the increased activity in scheduled public transport operations, the number of Immediately Reportable Matters has generally either remained stable or declined. When measured in relation to airline activity, the trend rate is generally downwards.

Violations of controlled airspace involve aircraft entering controlled or restricted airspace without appropriate clearances from air traffic control. There was a total of 82 airspace violations recorded over 5 years, and the ATSB found a downward trend for these incidents.

A breakdown of separation occurs when the distance between aircraft is less than that required. In many cases where separation breaks down the aircraft will still be some considerable distance apart. Of the 462 incidents recorded, only two per cent were serious enough to warrant further investigation by the ATSB. Breakdown of separation events have become more common, but only at about the same rate that airline activity has increased.

Other incidents examined by the ATSB include reports of crew incapacitation and cabin fumes. Serious crew injury or illness was rare, supporting the findings from an earlier study by the ATSB. The ATSB also received 140 notifications of fumes. Sources of fumes included oil or solvent residues following maintenance activities, failed or overheated electrical or mechanical components, or passenger's luggage. Smoke or fumes from burning food in the galley was also common.

The ATSB confirmed that accidents in Australian regular public transport operations are extremely rare. Only one accident involved fatalities, with the loss of all 15 people on board a regional airliner near Lockhart River. All other accidents were limited to damage to the aircraft, including damage to aircraft by service vehicles before flight, or injury to crew or passengers, including from unexpected turbulence during a flight.

The study highlights the value of a strong safety reporting culture and provided encouraging data concerning safety trends in Australian airline operations.

The Australian Transport Safety Bureau has found that heavy fog and the inappropriate speed of a truck in the conditions were the main contributors to a collision with a freight train at the Lismore Skipton Road level crossing at Lismore, Victoria on 25 May 2006. The 34 year old driver of the truck was fatally injured in the accident which closed the main Adelaide to Melbourne rail line for a period of six days with the total damage bill estimated at $13.5 million.

The collision occurred when the truck drove into the side of the second locomotive while the train was on the level crossing. This collision occurred shortly before sunrise with visibility in the fog as low as 20 metres and certainly no greater than 50 metres. The passive level crossing was fitted with give-way signs for road users and was not protected by lights or bells to indicate the presence of a train.

The truck was a 19 metre loaded rigid tipper/quad axle combination that was travelling south on the Lismore Skipton Road. The train was 1.3 kilometres long, weighed over 4300 tonnes, and was being hauled by three locomotives travelling east from Adelaide to Melbourne.

The locomotive data logger revealed that the speed of the train at impact was 112 km/h, that the locomotive horn was sounded twice before the collision and that the train's headlight was illuminated. The ATSB calculated the speed of the truck as being between 53 and 78 km/h, with the likelihood that it was towards the upper end of this range.

The force of impact was such that the second and third locomotives of the train were derailed and this resulted in a 'domino' effect that subsequently derailed 41 of the train's 64 freight wagons.

Other safety factors identified in the investigation that did not directly contribute to the collision were the possibility that the truck driver may have been suffering some effects of fatigue and also that the level crossing approach signage and sighting distances did not comply with relevant standards and guidelines. The investigation also noted that in times of reduced visibility it may not be possible for a motorist to safely negotiate a level crossing protected only by give way or stop signs based on sighting distances alone.

The report acknowledges the work being undertaken by the Australian Transport Council and the Australasian Railway Association in regard to the National Railway Level Crossing Safety Strategy and the safety actions already taken or underway by the National Transport Commission and VicRoads.

Recommendations are made to VicRoads and the Department of Infrastructure in relation to ensuring that other passive level crossings in Victoria are to standard, ensuring that road and rail authorities jointly assess the risks of large road vehicles traversing level crossings, and increasing road user education regarding the risks of passive level crossings.

The ATSB has found that an undetected flaw, and the subsequent failure of a critical main engine component, led to the bulk carrier Enterprise being disabled in Bass Strait on 10 July 2006 and drifting for nearly three days.

The Australian Transport Safety Bureau investigation has found that a microscopic flaw led to the failure of a main engine gudgeon pin. The investigation also found that the engine manufacturer did not provide sufficient guidance for monitoring the fatigue life of gudgeon pins and that the planning and execution of maintenance on critical items of equipment was inadequate.

At about 1540 on 10 July 2006, while Enterprise was en route from Adelaide to Newcastle, the main engine low lubricating oil pressure alarm sounded, indicating that the main engine's lubricating oil filter was choked. While the duty engineer was changing over to the spare lubricating oil filter, oil pressure was lost, causing the engine to stop. The engine was restarted and the voyage was resumed.

At 1805, the alarm sounded again and the engineers stopped the engine. At 2000, after inspections had been undertaken, the chief engineer advised the master that there was probably damage to the engine's bearings and that the ship would need to be towed to the nearest port for repairs.

At 1400 on 13 July, Enterprise was taken in tow by the tug Keera and towed to Melbourne, where it berthed at 1900 on 15 July. During the engine repairs in Melbourne it was discovered that one gudgeon pin had failed.

The ATSB has made three 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 collision between a freight train and motor car occurred because the flashing lights, bells and boom gates failed to operate as the train approached the level crossing.

The Australian Transport Safety Bureau has today released its final report into the investigation of a collision that occurred at the Chapple Street level crossing at Kalgoorlie in Western Australia on 14 May 2007.

At the time of the collision the Chapple Street level crossing was controlled by flashing lights, bells and boom gates. The investigation established that the level crossing protection system did not operate as intended because a temporary wiring strap had inadvertently been left in place by engineering staff while making modifications to signalling circuitry.

The investigation established that although WestNet Rail had procedures governing the use of the temporary wiring strap this did not prevent the mistake from occurring.

In the interest of enhancing future road/rail safety WestNet Rail has been proactive in adopting a number of recommendations that address various safety issues including the need to re-examine risk assessment and engineering maintenance/testing procedures in relation to rail signal systems.

Copies of the report can be downloaded from the ATSB's internet site.

The ATSB has found that four crew members who were injured on board the bulk carrier Shirane on 2 April 2007 were not aware of similar previous boiler explosions (flashbacks) which could have fore warned them.

The Australian Transport Safety Bureau investigation also found that the ship's crew were not aware of all of the hazards associated with servicing the boiler burner and that the personal protective equipment they were using did not provide them with adequate protection.

On the morning of 2 April 2007, Shirane was off Newcastle, New South Wales and the ship's third engineer had been assigned the task of replacing the Osaka OECV2 auxiliary boiler burner with a clean spare unit. When he finished the job, he attempted to fire the burner to check its operation but it failed to ignite. A few moments later, at 1013, while he was removing the burner to inspect it, there was a flashback from the boiler furnace.

The third engineer ran into engine control room and, as it was clear to the chief engineer and the first engineer that he had been burned, he was taken to the ship's hospital for first aid treatment.

The master was informed and, shortly after 1015, he telephoned the ship's agent in Newcastle and requested a medical evacuation.

After purging the boiler furnace for about an hour, the chief engineer and the second engineer removed the burner to inspect it. A few moments later, there was another flashback from the boiler furnace. The chief engineer, the second engineer and the fitter were burned by the second flashback.

The flashback had also caused a small fire on the deck, which was quickly extinguished. The three men then went to the ship's hospital for first aid treatment.

By 1324, a rescue helicopter had evacuated the second engineer, the third engineer and the fitter from the ship and, at 1729, it returned for the chief engineer.
The ATSB report found that the flashbacks were caused by unburnt fuel being deposited in the furnace when the burner misfired. The fuel was then vaporised and ignited by the hot surfaces inside the furnace.

The ATSB is pleased to report safety action already taken by the shipping company and the boiler manufacturer and has also issued three safety advisory notices with the aim of preventing similar occurrences.

The Executive Director of the Australian Transport Safety Bureau has today authorised the re-opening of the investigation into the crash of Whyalla Airlines VH-MZK. This is to enable the ATSB to seek the assistance of the US National Transportation Safety Board (NTSB) to conduct further testing of the MZK left engine crankshaft, which is currently in the US, including destructive testing at the site of the fracture.

The ATSB did not undertake such destructive testing in its original investigation because the detailed tests that were conducted indicated no crankshaft material problems and the ATSB did not wish to unnecessarily damage important evidence.

Clause 5.13 of Annex 13 to the Chicago Convention, as enacted in Australia through section 19DF(1) of the Air Navigation Act includes the requirement that: "If, after an investigation of an accident, serious incident or incident has been completed, new and significant information relation to the accident, serious incident, or incident becomes available, the Director must (a) if the investigation was conducted by the Director - conduct a further investigation of the circumstances surrounding the accident serious incident or incident". The ATSB has been assisting with, and closely monitoring, the progress of the Whyalla Airlines inquest in South Australia with this in mind.

The issuance by US engine manufacturer Textron Lycoming on 16 September 2002 of 'Mandatory Service Bulletin' No.553 for the first time included the MZK left crankshaft serial number V537912936 among the list of crankshafts possibly affected by a materials problem in the crankshaft manufacturing process.

Prior to the Whyalla inquest hearings in the US, it was hoped and expected that comprehensive testing of the left crankshaft fracture site would be jointly agreed and undertaken by McSwain (on behalf of the relatives of the deceased) with Lycoming in a timely manner. The engines are in the US as part of civil damages proceedings. The Coroner and parties had agreed to a protocol regime to allow for destructive testing as required. On that basis, the ATSB was prepared to await the outcome and formally re-open the ATSB investigation only if a significant material defect was established.

Ongoing delay with such testing has led to ATSB formally re-opening the investigation based on the 16 September 2002 service bulletin alone. The ATSB has also been told that some US litigation settlements require that engine parts be destroyed - such a loss of evidence would, of course, undermine the current inquest and future aviation safety. ATSB wishes to ensure that every effort is made to test the crankshaft without delay to resolve the question of whether a manufacturing material problem was a causal factor.

The US NTSB has informally advised today that as the engines are in the US, it would be prepared to test the left crankshaft in its laboratories for a materials defect at the site of the fracture if the ATSB re-opens its investigation and requests this assistance under Chicago Convention protocols. The ATSB would do so following the SA Coroner's agreement. The NTSB will not become involved in Australian or US legal proceedings.

The ATSB's final investigation report into an aircraft accident near Willowbank in Queensland last year, resulting in five deceased persons and two seriously injured survivors, found that the aircraft's performance prior to impacting a large tree and crashing into a dam was consistent with an engine power loss.

The Australian Transport Safety Bureau report states that technical examination of the Cessna 206's engine and its associated components did not reveal anomalies with the potential to have individually contributed to the partial engine power loss and loss of climb performance about 100 feet above ground level.

The investigation could not discount the potential that a number of less significant anomalies that were identified, may have coincided on 2 January 2006 to reduce the available engine power.

Laboratory examination of the fuel used in the aircraft was found to be outside specification. However, fuel quality experts that were consulted during the investigation indicated that there was minimal potential for the quality of the fuel to have negatively affected the engine's performance.

The investigation determined that the aircraft was being operated in an overweight condition, but because of limitations in the available performance information on the highly-modified aircraft, the effect of that overloading could not be quantified.

The report outlines safety action taken by the Australian Parachute Federation (APF) and contains seven safety recommendations to the APF, the Civil Aviation Safety Authority and the US Federal Aviation Administration to enhance future safety.

As a result of this and a number of other accidents involving partial engine power loss, the ATSB has initiated a special investigation into the factors that affect loss of control following engine power loss (including partial power loss) after takeoff.

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

The first ATSB graduates from the recently accredited Diploma of Transport Safety Investigation were presented with their awards on 18 October 2002.

Senior ATSB investigators Alan Stray, Kit Filor and Kerryn Macaulay received their Diplomas after successfully completing the streamlined assessment process aimed at recognising prior learning and current competency.

Awards were also made to 12 staff who successfully completed a Certificate Level 4 course in Assessment and Workplace Training. This qualifies them to train and assess at the Diploma level.

The awards are the first since the Bureau received its recent national accreditation for the Diploma program and accreditation as a Registered Training Organisation (RTO).

In presenting the awards Kym Bills, Executive Director of the Bureau, noted that the transport safety investigation course is believed to be the first of its type in the world. There has been domestic and international interest in the course already expressed from industry, transport regulatory authorities and other government bodies.

Mr Bills noted that this is an excellent achievement for the Bureau and re-inforces the world-wide standing of ATSBs safety investigation capability.

The Diploma course is aimed at providing basic investigation training to investigators in air, marine and rail transport modes. The course offers a structured learning framework through a combination of formal course work, self-paced learning guides and on-the-job training to provide trainees with the essential knowledge, skills, experience and competencies.

Duration of the course will vary according to current competency and prior learning, but new recruits could complete the course in 18 months as an integral part of their work in the Bureau. The course also links to investigator Work Level Standards.

The Diploma program will cover a range of generic and technical competencies relevant to transport safety investigation. These include technical report writing, data collection and analysis, and the final competency of managing a (less complex) transport safety investigation.

Development of the course commenced in 2000 when the Bureau identified the need for a vocational educational and training qualification to address the requirements of Transport Safety Investigators. The Bureau realised that a structured learning program would be necessary to develop the skills of new recruits before more experienced investigators leave the organisation. In addition, the Diploma could also prove useful in the context of the increasingly litigious environment in which the Bureau operates.

With the focus of the Bureau on no-blame safety investigations, it was not possible to simply adopt existing investigation courses aimed at apportioning fault or blame. The Bureau, with assistance from the Canberra Institute of Technology (CIT) Solutions, developed its own enterprise-specific standards consistent with its no-blame safety investigation philosophy and the Bureaus international obligations and legislation.

In addition to offering a Diploma for successful completion of the full course, the Bureau may now also offer Certificates to successful external candidates of short courses conducted by the Bureau such as the well-known course on Human Factors for Investigators.

Administration of the RTO will be in accordance with the national standards issued by the Australian Quality Training Framework. All aspects of the course will be continually monitored and evaluated to ensure the training remains effective and relevant to the needs of the Bureau.

Opportunities may exist for commercial development of the course. However, the immediate ATSB priority is to ensure ATSB staff obtain the full benefit from what the course has to offer to maintain Australias position at the forefront of transport safety investigation.

The Australian Transport Safety Bureau has released its final report after an almost two-year investigation of the systemic factors behind the groundings of Ansett B767 aircraft.

While Ansett has ceased flying, the ATSB continued its investigation because of the importance of the issues involved for the safety of 'Class A' aircraft around the world.

The ATSB found that in addition to errors and omissions by individuals in Ansett, there were deeper system and resource weaknesses in the airline group and shortcomings by the US regulator of the aircraft type (the FAA) both of which CASA was unaware.

The Boeing 767 aircraft was among the first in the world to be designed and certified under damage tolerance principles. This meant that while some aircraft structural fatigue cracking was expected, a robust system for regular inspection and maintenance was essential to assure continuing airworthiness.

Ansett omitted to action 25,000 flight cycle inspections issued by Boeing in June 1997 and updated in June 2000 to include fatigue crack inspections of the aircraft tail. It also failed to action within the recommended six months a March 2000 Boeing 'Alert' service bulletin relating to possible cracking in B767 engine mount fittings.

The FAA did not mandate Boeing's June 1997 inspections and subsequent service bulletins until after the second Ansett groundings in April 2001. Boeing did not highlight the potential safety significance of the tail cracking issue in its service bulletin until November 2001 - prior to this Boeing's focus was on it being a commercial issue.

The former CAA had reduced the Australian regulator's in-house capacity to review important safety service bulletins and relied on foreign regulators like the FAA and operators like Ansett to do so. CASA was unaware of delays in the FAA and did not appreciate the extent of problems involving Ansett's maintenance. Vulnerability was compounded by weaker than desirable feedback systems for maintenance issues.

The action by Ansett and CASA to ground the B767 aircraft until safety could be assured protected the flying public. The ATSB issued two recommendations in April 2001. CASA also conducted an extensive review and is addressing its findings.

The ATSB is today making a further 11 recommendations to ICAO, the FAA, and CASA designed to augment the safety defences for Class A aircraft such as the B767.

The Ansett 767 maintenance case highlights the need for organisations to be continually mindful of potential threats to aviation safety, particularly when commercial pressures intensify and there are significant changes to structures and the broader environment.

Failure to keep a proper lookout, a faulty radio and fatigue resulted in a collision between two vessels off the coast of Western Australian on 18 January 2001, according to an investigation report released by the Australian Transport Safety Bureau today.

The report states that the collision occurred at 0435 local time, 14 miles off the coast when the rock lobster fishing vessel, Lipari, struck the side of the Hong Kong flag bulk carrier, Handymariner. The ship sustained no damage in the incident but the fishing vessel was holed on the starboard bow above the waterline. There were no injuries sustained by the crew of either vessel.

Lipari had left Port Bouvard, south of Fremantle, earlier on the morning of the incident to check lobster pots set some 36 miles offshore. Shortly after leaving port, the vessel's two deckhands had gone below to sleep while the skipper stayed in the wheelhouse with the vessel's autopilot engaged.

The mate on watch on the south-bound Handymariner had detected Lipari on radar some 25 minutes before the collision. He had attempted to call the fishing vessel on marine radio but Lipari's radio was not working and so his calls went unheard. The mate then attempted to warn the fishing boat using a signal lamp and the ship's whistle but still received no response. Lipari had maintained a steady course and speed towards the ship. When the collision was imminent, the mate had altered the ship's course to starboard.

Just before the two vessels collided, the skipper in Lipari's wheelhouse had heard the ship's whistle. He realised at that point that there was a ship dead ahead and so turned the fishing vessel's helm hard to port to try to avoid the collision.

The report concludes that the look-out maintained on Lipari was inadequate, with the lack of an operational VHF marine radio on the vessel also contributing to the incident. The investigation also revealed that it was probable that Lipari's skipper was suffering from some affects of chronic fatigue which may have led to his poor situational awareness and poor look-out in the time leading up to the collision.

The report recommends that all commercial vessels operating offshore be required to carry operational VHF radio equipment and that State and Territory marine authorities review work practices and manning levels on fishing vessels to establish guidelines for the management of crew fatigue.