The final report on the Beech Super King Air 200 VH-SKC accident, in which all eight occupants died when a charter flight from Perth on 4 September 2000 overflew Leonora and then the NT before crashing near Burketown QLD, was released today by the Australian Transport Safety Bureau.

ATSB Executive Director, Kym Bills, made the following statement:

"Based on the available evidence, including voice analysis of air traffic control tapes, the investigation concluded that the pilot and passengers were probably incapacitated as a result of hypobaric (altitude) hypoxia due to the aircraft being unpressurised and their not receiving supplemental oxygen.

The extent of damage to the King Air after it impacted the ground at about 240 kts (445 km/h) and the constraints associated with the subsequent autopsies as a result of the hot, remote crash site, made this investigation particularly difficult.

However, testing established that carbon monoxide and hydrogen cyanide were unlikely to have been factors.

The reason for the aircraft probably being unpressurised (such as lack of hull integrity and/or bleed air not operating) or why the pilot and passengers did not receive supplemental oxygen to prevent hypobaric hypoxia, could not be determined from the evidence.

The investigation concluded that setting the aircraft's visual alert to operate when the cabin altitude pressure exceeded 10,000 feet rather than 12,500 feet and adding an aural warning to operate in conjunction with the visual alert, may have prevented the accident.

In December 2000 the ATSB made recommendations to CASA along these lines based on an earlier occurrence, which the regulator has accepted."

The final report into the investigation of the grounding of the Wyuna in the Tamar River, Tasmania on 19 October 2000, has concluded that crew fatigue may have been a contributing factor. The report was released today by the Australian Transport Safety Bureau.

The Australian training vessel had grounded on Shear Rock after the master gave a series of incorrect course orders to a student under training.

The vessel was carried northward by the tide and grounded again on Middle Bank before the master was able to manoeuvre the vessel into the channel. There were no injuries and no pollution of the river.

The master took the vessel back to its anchorage at Bell Bay while continuously checking for damage. Numbers 10 and 11 tanks were slowly taking water which indicated a leak through sprung seams and rivets.

The report concluded there was insufficient oversight of the vessel's operation by the Australian Maritime College. The master's loss of concentration and inability to identify the vessel's correct position was possibly due to fatigue.

It is also possible that fatigue was the reason for the master setting an incorrect course and insistence that the course be maintained.

It was noted in the report that the three students on the bridge at the time of the accident did not challenge the master's divergence from the voyage plan.

The investigation has recommended that the Australian Maritime College implement an appropriate safety management system for the vessel, and that a daily record of hours worked by each crew member be maintained. This would facilitate the monitoring of fatigue levels of individual members of the crew.

The report can be downloaded from the website: or by telephoning 1800 020 616.

The Australian Transport Safety Bureau (ATSB) will release its final report into the systemic factors behind the groundings of Ansett B767 aircraft, tomorrow.

Several of Ansett's B767 aircraft were grounded in December 2000 and again in April 2001. 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.

Executive Director Kym Bills will speak to the media at 10.30am tomorrow, at the ATSB headquarters at 15 Mort St, Braddon.

Who: ATSB Executive Director Kym Bills.
When: 10.30am, Friday 15 November.
Where: 15 Mort Street, Braddon.

The report will then be available from 10.30am, as will a broadcast-quality recording of the ATSB statement.

Note: Mr Bills will not be available for interviews following the media conference.

A report released today by the Australian Transport Safety Bureau (ATSB) has found that limited visibility in heavy rain was a significant factor in a collision involving the Australian fishing vessel Chinderah Star and the Liberian flag bulk carrier Silver Bin.

The collision occurred at 1209 local time on 25 March 2000, 0.6 nautical miles west of Chapman Island in the inner route of Queensland's Great Barrier Reef.

Approximately 24 minutes before the collision, Chinderah Star was heading north when its skipper identified Silver Bin, 8.6 nautical miles to the north and heading south. The skipper realised that the two vessels would pass at close quarters in a narrow section of the shipping channel but did not make radio contact with the ship or alter the vessel's course.

Twelve minutes later Chinderah Star and Silver Bin were enveloped in heavy rain when a tropical rainsquall entered the shipping channel. The crew of Silver Bin had not identified Chinderah Star before entering the rainsquall and despite the estimated visibility of 160 metres neither vessel reduced speed or sounded any audible signals.

The report concluded that the crew of both vessels did not properly assess the risks of collision in the heavy rain, with the limitations of marine radar in such conditions being a contributing factor in the collision.

Since 1 July 1999, the ATSB has investigated six collisions involving ships and fishing vessels or small craft. Such collisions keep occurring despite the widespread circulation of ATSB reports and safety bulletins as well as media coverage.

The report on the collision between Silver Bin and Chinderah Star emphasises the importance of maintaining an effective lookout in all conditions and navigating at a safe speed in conditions of reduced visibility.

ATTENTION: Editors/Chief of Staff, Aviation/transport writers

The Australian Transport Safety Bureau will be conducting a Media conference to discuss aspects of the Coroner's findings of the inquest into the Beech Super King Air aircraft which crashed 65km SE of Burketown on 5 September 2000 with eight fatalities.

The conference will be held at 4 PM TODAY, Thursday 12 September.

When: 4 pm. Please arrive in the foyer no later than 3.45pm as we need to escort you to our conference room
Where: The Australian Transport Safety Bureau at 15 Mort Street, Canberra City.

At 3.30pm today, the Australian Transport Safety Bureau will release its final investigation report on the fatal aircraft crash near Newman, WA.

On 26 January 2001, a Cessna 310R operated by the Western Australian Police Air Support Unit crashed at night near Newman aerodrome.

The four occupants sustained fatal injuries. Impact forces destroyed the aircraft.

Who: ALAN STRAY (ATSB Deputy Director of Air Safety Investigation)
When: 3.30pm (Eastern Standard Time)
Where: ATSB Headquarters, 15 Mort Street, Canberra

The report, titled Air Safety Investigation Report 200100348, will be available online at www.atsb.gov.au.

Note: Media will then be able to download an audio statement from approximately 3.40pm.

ATTENTION: Editors/Chief of Staff, Aviation/transport writers

The earlier invitation to attend a MEDIA CONFERENCE

About the Beech Super King Air aircraft which crashed 65km SE of Burketown on 5 September 2000 with eight fatalities, has been amended.

The conference will now be held at 4 PM TODAY, Thursday 7 March.

When: 4 pm. Please arrive in the foyer no later than 3.45pm as we need to escort you to our conference room.
Where: The Australian Transport Safety Bureau at 15 Mort Street Braddon, Canberra.

A hard copy of the report will then be available.

The ATSB's final investigation report into a Piper Chieftain accident near Condobolin, NSW on 2 December 2005, resulting in four deceased persons, confirms that the aircraft broke up during flight when its structural limits were exceeded in the vicinity of thunderstorms.

The Australian Transport Safety Bureau report states that there was no indication, either by way of emergency radio transmission from the pilot, or in a change in the altitude, track and speed of the aircraft as recorded by radar, that the flight was not proceeding normally. Some minutes after the pilot reported diverting left of track to avoid weather, communications with the aircraft were lost.

The absence of an on-board recording device on the aircraft prevented a full analysis of the circumstances of the breakup. However, while post-impact fire damage limited the extent to which some of the aircraft's system's, including the fuel and electrical systems, could be examined, wreckage examination did not reveal any pre-existing fault or condition that could have weakened the aircraft structure and caused it to break up at a load within the design load limit.

A line of severe thunderstorms crossed the aircraft's planned track and were the subject of a SIGMET (significant weather advice) issued by the Bureau of Meteorology. As the SIGMET information did not meet the criteria for direct notification, it was not advised directly to the pilot of the aircraft. The investigation was unable to determine if the pilot had obtained the SIGMET from any of the range of pre and in-flight weather briefing services available to the pilot.

Analysis of the prevailing weather indicated that, immediately before the accident, the aircraft was likely to have been surrounded to the east, west, and south by a large complex of thunderstorms. That situation may have limited the options available to the pilot to avoid any possible hazardous phenomena associated with the storms.

Although, as a result of a review of Flight Information Service initiated in November 2004, Airservices Australia had identified inconsistencies and ambiguities in the provision of Flight Information Service, including Hazard Alert procedures, they were not assessed by the investigation to be contributing factors to the accident. As a result of its review, Airservices Australia initiated changes to the Flight Information Service and Hazard Alerts sections of the Manual of Air Traffic Services and the Aeronautical Information Publication to improve future safety.

While not contributory to the accident, the report identifies a number of inconsistencies between Australian SIGMET issemination procedures and those contained in International Civil Aviation Organization (ICAO) documentation. The report contains recommendations to Airservices Australia and the Civil Aviation Safety Authority to review Australian procedures with a view to minimising those inconsistencies.

The circumstances of the accident are a salient reminder to pilots of their responsibilities to request weather and other formation necessary to make safe and timely operational decisions, and of the importance of avoiding thunderstorms by large margins.

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

The ATSB has found that a lack of communication, hazard awareness and job safety analysis led to a seaman on board the Panamanian registered container ship MSC Sonia being severely burned by steam.

The Australian Transport Safety Bureau investigation also found that the placement of the boiler safety valve vent pipe, and the direction in which it exhausted, meant that any personnel on the funnel casing top platform were vulnerable when a boiler safety valve operated.

At about 0900 on 10 April 2007, a surveyor arrived on board MSC Sonia to carry out a scheduled boiler survey while the ship was alongside Swanson Dock, Melbourne.

The ship's chief engineer and the surveyor went to the engine room and, after visually inspecting the outside of the boiler; they tested the safety cut-out devices. The surveyor then asked for the operation of the safety valves to be tested. The turbo-alternator was shut down to reduce the steam demand and the boiler's two burners were fired manually. The steam pressure started to rise and, at about 0945, when the boiler pressure reached 11 bar, the safety valves operated.

The ship's boatswain and the ordinary seaman had spent all morning on the top platform of the funnel casing painting the main engine exhaust pipes. At about 0945, steam unexpectedly exhausted from the nearby boiler safety valve vent pipe, directly onto the ordinary seaman.

The ordinary seaman was severely burned by the steam. He was assisted down the funnel casing ladder and onto the bridge deck. While he lay on the deck, the crew used a hose to shower him with water to cool his burns.

At 1015, an ambulance team arrived on board the ship and, by about 1100, the ordinary seaman had been landed ashore, placed in the waiting ambulance and taken to hospital.

The ATSB is pleased to report safety action already taken and has issued one safety recommendation and two safety advisory notices with the aim of preventing similar incidents.

The ATSB has found that a fatal collision between The Overland passenger train and tip truck towing a tri-axle trailer occurred because the truck driver probably did not see the train and entered the level crossing after braking too late to stop at the 'Stop' sign.
The Australian Transport Safety Bureau has today released its final report on the investigation of the collision which occurred at the Barpinba-Poorneet Road level crossing, near Wingeel in southern Victoria, on 15 November 2006.

At the time of the accident the crossing was controlled by passive 'Stop' signs and approach warning signs. The investigation established that the truck did not come to a halt at the 'Stop' sign controlling the crossing and concluded that the driver was possibly distracted by the presence of the road-junction ahead. The truck driver was probably unaware of the presence of the train until just before the collision.

The investigation also found that the viewing angle in the direction from which the train approached the crossing was poor. When coupled with the restricted visibility from the truck's cab, it would have been difficult for the truck driver to see the train without coming to a complete stop at the crossing. The investigation also found that when approaching the crossing from the south-west the advance warning signs did not comply with the operative Australian Standard AS 1742.7: Manual of uniform traffic control devices - Railway crossings.

The investigation established that in the circumstances there was nothing that the train crew could have done to prevent the accident.

In the interest of enhancing future road/rail safety the ATSB has made a series of recommendations to address safety issues including the poor viewing angle at the crossing and the non-compliance of the level crossing signage with the relevant standard.

Read the report: Collision between Rigid Tipper Truck/Tri-axle Trailer and The Overland Passenger Train, 4AM8, Wingeel, Victoria, on 15 November 2006