An ATSB report released today shows that the average age of many aircraft in Australia is increasing but that this should not reduce safety if quality maintenance systems are in place.

The Australian Transport Safety Bureau (ATSB) report found that the average age of Australia's turbofan aircraft used in regular passenger transport (RPT) is very low. The fleet of aircraft in the 50,000 kg to 100,000 kg category had an average age of just 6 years by the end of 2005. That was 2 years lower than the average age of this fleet in 1995.

The expansion of Qantas, and the introduction of new aircraft by Jetstar and Virgin Blue has lowered the average age of these aircraft. Aircraft in this category include the Boeing 737 and Airbus A320, typically used in Australian domestic passenger operations, and on some international routes.

The fleet of larger turbofan aircraft (those above 100,000 kg, including the Boeing 747 and the Airbus A330) have an average age of 11 years. This is still relatively low, and consequently, there would be few signs of maintenance problems related to aircraft age in these aircraft.

The ATSB report also examined the age trend for turboprop aircraft, mostly used in low-capacity airline services. Examples of turboprop aircraft operated in Australia include the Raytheon King Air and the Fairchild Metroliner series of aircraft. The turboprop fleet had an average age of 18 years by the end of 2005, which was 2 years older than was the case in 1995. With few new aircraft being manufactured in this category, additional and specific maintenance will be the key strategy to ensure these aircraft meet the necessary airworthiness standards for passenger operations.

The oldest aircraft in Australia are those powered by piston engines. These aircraft, ranging from the small single engine aircraft used at flying schools and in private operations (such as the Cessna 172), to the twin engine aircraft (for example, the Piper Navajo and the Cessna 400 series) used in charter and some low-capacity operations, are on average around 30 years old.

The situation affecting piston-engine aircraft is not a challenge just for Australia. Manufacturing output of these aircraft is only a fraction of the production levels seen in the late 1970s, and some popular twin-engine types ceased production altogether in the mid 1980s.

The ATSB report on aircraft age makes clear that chronological age is not the sole determinant in assessing aircraft age. Flight cycles and maintenance regimes are important factors that influence airworthiness.

Managing the consequences of an ageing aircraft population requires cooperative approaches by operators, manufacturers and national regulators to ensure that any defects identified by one operator are notified quickly and efficiently within the industry. If quality maintenance systems are in place, ageing aircraft need not lead to reduced safety.

Copies of the report can be downloaded from the 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 collision between a train and low loader truck occurred because the truck driver was probably distracted and did not see the train approaching.

The Australian Transport Safety Bureau investigated the collision which occurred at the Magpie Drive level crossing, Tailem Bend, South Australia, on 4 October 2006.

At the time of the accident the crossing was controlled by passive 'Stop' signs and approach warning signs. It is likely that the truck did not come to a halt at the 'Stop' sign controlling the crossing as the driver was possibly distracted by the presence of the road-junction ahead and/or a preoccupation with arriving at his destination on time, which may have diverted his attention from the risks associated with negotiating the level crossing.

The investigation also found that the viewing angle to the north-west of the crossing was substandard and coupled with restricted visibility from the truck driver's cab would have made it difficult for the truck driver to sight the train.

The investigation established that there was nothing 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 which include opportunities for closure of the level crossing and/or options for improving sighting and viewing angle, enhancing train conspicuity, and expanding the role of the Department for Transport, Energy & Infrastructure Level Crossing Unit's role to include an ongoing level crossing education and audit role.

According to the ATSB investigation, the 'knockdown' of the sail training vessel Windeward Bound, in Bass Strait, was the result of inadequate preparations by the ships crew and the use of excessive rudder movements at the time that a forecast severe cold front passed over the vessel.

On 3 June 2004, Windeward Bound was off the Victorian coast, heading northeast at about six knots. The wind was from the northwest and the vessel was heeled between 10 and 15 degrees to starboard. The upper and lower topsails, the main and fore staysails were set. While a cold front was expected, the ship's master was unaware of the impending gale force winds repeatedly forecast.

At 1726 the helmsman was instructed to run the vessel downwind and shortly thereafter the vessel yawed to port and the helmsman put the rudder hard over to starboard. The watch leader then took the helm and, as the vessel was now swinging to starboard, applied a 'considerable amount' of port rudder. When the vessel had started to swing to port, the rudder was put hard over to starboard to arrest the swing. A gust of near-hurricane force wind then heeled the vessel about 68 degrees to starboard. The vessel was righted after several minutes using the main engine and the rudder and by letting the sheets go.

There was a minor injury to a crew member during the incident and the main engine had been damaged after being run with little or no lubricating oil pressure while the vessel was heeled.
During the next twenty-four hours contact was lost with authorities ashore because of a failure of the ship's generator. An air search was initiated on the afternoon of 4 June and Windeward Bound was found safe and heading for Jervis Bay where it arrived late in the evening of 5 June.

The ATSB investigation found that the ship was not adequately prepared for the passage of the front and that the use of excessive rudder movements caused the vessel to slow sufficiently to broach and then be knocked down.

Significant safety action has already taken place and the ATSB has issued three safety recommendations and one safety advisory notice 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 ATSB is reviewing scope for possible action against Transair but re-emphasises that this is unrelated to the Transair accident on 7 May 2005 when all 15 on board lost their lives.

The Deputy Prime Minister as Minister for Transport and Regional Services has today been informed that earlier advice from the ATSB suggesting that it was unable to pursue any prosecution with respect to some more serious incidents that Transair failed to report before the accident was incorrect. The ATSB has apologised to the Minister.

The ATSB wishes to highlight that it is an independent safety investigator and not a body that prepares charges after an accident. Its only charge-related role is in relation to breaches of the Transport Safety Investigation Act 2003 (TSI Act), such as through the non-reporting of incidents, and not any charges in relation to the accident itself.

Any prosecution action against Transair and its officers in relation to the fatal accident itself is a separate matter.

As stated in the ATSB's media release of 1 December 2006 and in evidence to the Senate on 15 February 2007 the ATSB uncovered that Transair failed to report 7 immediately reportable matters (IRMs) that occurred between 1 July 2003 and the accident, as well as more routine matters. They include a gear failure on departure from Bamaga, a burning smell near Inverell, and a problem with flaps leading to a flapless takeoff and flight issues from Gunnedah to Sydney. But none of these incidents was linked to the 7 May 2005 fatal accident.

Under the TSI Act such IRMs must be reported immediately by responsible persons (eg Transair) in accordance with the regulations and failure to do so has a maximum penalty of imprisonment for six months (TSI Act Section 18). The Director of Public Prosecutions (DPP) advised the ATSB that under the Crimes Act 1914 a 12-month statute of limitation applied to Section 18 and also with respect to individuals' written reports under Section 19.

However, the DPP also advised that under Section 19 of the TSI Act failure to make a written report of IRMs by a company (ie Lessbrook Pty Ltd trading as Transair) within 72 hours (which carries a maximum penalty of up to 300 penalty units or $33,000) is not time-barred.

The ATSB mistakenly drew the conclusion that all TSI Act prosecution action in relation to IRM incident reports was time barred and will now work with the DPP as a matter of priority to see if a viable prosecution case can be prepared in relation to Section 19.

Separately, the time limits for a prosecution under the TSI Act are being reviewed.

The ATSB has found that the crew on board the Isle of Man registered oil tanker British Mallard did not prevent the ship's elevator car from moving while they were working in the elevator shaft and, as a result, it moved unexpectedly, trapping and killing the ship's electrical technician.

The Australian Transport Safety Bureau investigation found that the ship's crew were either not aware of, or did not consider, all of the hazards associated with working in the elevator shaft. The investigation also found that the elevator instruction manuals did not provide detailed and unambiguous safety guidance; and that critical safety procedures had not been implemented.

At about 1750 on 27 January 2007, British Mallard's crew attempted to repair an elevator fault before they finished work for the day.

The electrical technician made some adjustments to the second deck elevator landing doors and, at about 1800, he stepped into the elevator shaft.

At the electrical technician's request, the second deck elevator landing doors were allowed to close behind him. When the doors closed, the landing door safety circuit was completed and the elevator control system then reset itself.

It is likely that someone then attempted to use the elevator and did not notice the 'do not operate' signs that had been placed on the elevator doors and was unaware that the elevator was not to be operated.

The elevator car then started to move upwards. Its movement was eventually obstructed by the electrical technician and the resultant damage to the elevator car caused it to stop.

The ATSB has reported safety action already taken and issued one safety recommendation and two safety advisory notices with the aim of preventing similar accidents.

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

The ATSB has found it is likely that some passive level crossings in the Northern Territory, Queensland, Western Australia and South Australia that are controlled by 'Stop' signs and are used by high combined gross mass road vehicles may have deficient sighting distances.

The Australian Transport Safety Bureau has released a supplementary report on this potential problem as part of its continuing investigation into the 12 December 2006 collision involving The Ghan on the Fountain Head Road level crossing at Ban Ban Springs, NT.

The Fountain Head Road level crossing signage at Ban Ban Springs directs road users to stop at the level crossing and to give way to trains that may be either on or approaching the level crossing at a line speed of up to 115 km/h. The road intersects the rail line at 90 degrees in a north-south direction with a slight rising grade for vehicles approaching from the north and with slight road curvature either side of the level crossing.

While not a factor in The Ghan collision, ATSB investigators identified that the time taken for larger road trains commonly used in the Northern Territory, Queensland, Western Australia and South Australia to traverse level crossings, and the available sighting distance, may be a safety issue.

The ATSB organised a timing trial to test the adequacy of the level crossing sighting distances by measuring a range of clearance times for the largest road-train combinations which routinely use the Fountain Head Road level crossing at Ban Ban Springs (and indeed similar crossings in the NT, and other states).

B+2A Road-Train Combination

Tests conducted on 53.5 m long B+2A road-trains at the Fountain Head Road level crossing, Ban Ban Springs, found that the theoretical models used to calculate sighting distance were likely to be inadequate for the truck configuration tested. It is probable that sighting distances at other level crossings controlled by 'Stop' signs, used by high combined gross mass road vehicles, may be similarly deficient and more research is needed to accurately assess this risk.

Accordingly, the Australian Transport Safety Bureau has advised that State and Territory road transport authorities and rail regulators should consider the implications of this safety issue and take action where it is considered appropriate.

Read the report: Level Crossing Collision between The Ghan Passenger Train (1AD8) and a Road-Train Truck, Ban Ban Springs, Northern Territory, on 12 December 2006

The ATSB has released a 500-page final report into Australia's worst civil aviation accident since 1968. The report spells out contributing safety factors involving the pilots, the operator and the regulator as well as other safety factors, and has made further recommendations to improve future safety.

An Australian Transport Safety Bureau team of a dozen investigators has taken nearly two years of painstaking investigation to complete the final report since the tragic accident on 7 May 2005 which killed both pilots and all 13 passengers. Three ATSB factual reports, a research report and ten safety recommendations were released in the interim. The investigation was complicated by an inoperative cockpit voice recorder, no witnesses, and the extent of destruction of the aircraft.

The ATSB found that a mechanically serviceable Metro 23 aircraft operated by Transair was unintentionally flown into South Pap ridge in poor weather during a satellite-based instrument approach, probably because the crew lost situational awareness in low cloud.

The experienced 40-year old pilot in command was very likely flying the aircraft but was reliant on the 21-year old copilot to assist with the high cockpit workload. He knew the copilot was not trained for this type of complex instrument approach. Despite the weather and copilot inexperience, the pilot in command also used approach and descent speeds and a rate of descent greater than specified in the Transair Operations Manual, and exceeded the recommended criteria for a stabilised approach. The pilot in command had a history of such flying.

The investigation found significant limitations with Transair's pilot training and checking, including superficial training before pilot endorsements and no 'crew resource management'. Deficiencies also existed in the supervision of flight operations and standard operating procedures for pilots. There were also significant limitations in the way Transair managed safety, Transair's management processes and because the chief pilot was over-committed with additional roles as CEO, the primary check and training pilot, and working regularly in Papua New Guinea.

The regulatory oversight was also not as good as it could have been, especially when Transair moved from a charter to a regular passenger transport operator and was growing rapidly in Australia. In addition to the serious pilot and company contributory factors, if CASA's guidance to inspectors on management systems and its risk assessment processes had been more thorough, the accident may not have occurred.

The ATSB investigation also identified a range of other safety issues which could not be as clearly linked to the accident because of limited evidence. These included shortcomings in the design of the navigation chart used and the possibility of poor crew communication in the cockpit.

The ATSB hopes that this final report will assist the families and friends of those who perished in this tragedy to move towards closure, and will lead to further improvements in aviation safety to ensure that such an accident never happens again.

An ATSB report released today shows that the average age of many aircraft in Australia is increasing but that this should not reduce safety if quality maintenance systems are in place.

The Australian Transport Safety Bureau (ATSB) report found that the average age of Australia's turbofan aircraft used in regular passenger transport (RPT) is very low. The fleet of aircraft in the 50,000 kg to 100,000 kg category had an average age of just 6 years by the end of 2005. That was 2 years lower than the average age of this fleet in 1995.

The expansion of Qantas, and the introduction of new aircraft by Jetstar and Virgin Blue has lowered the average age of these aircraft. Aircraft in this category include the Boeing 737 and Airbus A320, typically used in Australian domestic passenger operations, and on some international routes.

The fleet of larger turbofan aircraft (those above 100,000 kg, including the Boeing 747 and the Airbus A330) have an average age of 11 years. This is still relatively low, and consequently, there would be few signs of maintenance problems related to aircraft age in these aircraft.

The ATSB report also examined the age trend for turboprop aircraft, mostly used in low capacity airline services. Examples of turboprop aircraft operated in Australia include the Raytheon King Air and the Fairchild Metroliner series of aircraft. The turboprop fleet had an average age of 18 years by the end of 2005, which was 2 years older than was the case in 1995. With few new aircraft being manufactured in this category, additional and specific maintenance will be the key strategy to ensure these aircraft meet the necessary airworthiness standards for passenger operations.

The oldest aircraft in Australia are those powered by piston engines. These aircraft, ranging from the small single engine aircraft used at flying schools and in private operations (such as the Cessna 172), to the twin engine aircraft (for example, the Piper Navajo and the Cessna 400 series) used in charter and some low capacity operations, are on average around 30 years old.

The situation affecting piston-engine aircraft is not a challenge just for Australia. Manufacturing output of these aircraft is only a fraction of the production levels seen in the late 1970s, and some popular twin-engine types ceased production altogether in the mid 1980s.

The ATSB report on aircraft age makes clear that chronological age is not the sole determinant in assessing aircraft age. Flight cycles and maintenance regimes are important factors that influence airworthiness.

Managing the consequences of an ageing aircraft population requires cooperative approaches by operators, manufacturers and national regulators to ensure that any defects identified by one operator are notified quickly and efficiently within the industry. If quality maintenance systems are in place, ageing aircraft need not lead to reduced safety.

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

The ATSB has found that a high-pressure oxygen system fire on board the roll-on/roll-off cargo ship Searoad Mersey, on 22 September 2006, occurred when an unsuitable replacement hose fitted to the system ignited. The ship's trainee engineer was hit in the head by the gas pressure regulator and received burns to his face, head and arms.

At about 1540 on 22 September 2006, the trainee engineer was preparing the fixed oxy-acetylene system for a small hot-work job when two of the oxygen system's high-pressure hoses, and the oxygen regulator, exploded in a flash fire.

It is probable that, when the trainee engineer opened the cylinder's valve, the heat created by the compression of the oxygen in the line ignited the lining in one of a pair of replacement high pressure hoses that had been recently fitted to the system.

The replacement hoses were not designed for use in a high-pressure oxygen system. The hose liners had a low ignition temperature, the hoses were probably assembled in an oily environment, and the hose material did not comply with the appropriate standards for high pressure oxygen hoses.

The ATSB report also found that the hose assembler who supplied the hoses was not aware of any special requirements for high pressure oxygen systems when he assembled the hoses. Similarly, the ship's engineers were not aware of all of the hazards associated with high pressure oxygen systems or of the standards required for them.

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

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