The ATSB has found that the use of starboard instead of port helm led to the grounding of the Singapore registered woodchip carrier Crimson Mars in the River Tamar on 1 May 2006.

The Australian Transport Safety Bureau investigation found that an unsuitable conning position, ineffective bridge resource management and the distraction caused by the use of a mobile telephone may have contributed to the helm being applied the wrong way. It was also found that inadequate monitoring of the helm orders and their execution led to the error not being detected in time to prevent the grounding.

At 1400 Australian Eastern Standard Time on 1 May, Crimson Mars, nearly fully loaded with a cargo of woodchips sailed from Bell Bay with a pilot on board. The sky was cloudy, visibility was clear with a light south-easterly wind and the tide was flooding. The ship's master and third mate were on the bridge for the pilotage and a helmsman was steering the ship as instructed by the pilot.

The pilotage progressed as intended by the pilot until about 1440 when a turn to port around Garden Island, a critical part of the passage, was being executed. During the turn, starboard instead of port helm was applied for approximately one minute. By the time the error was detected and maximum port helm applied at about 1441, grounding was inevitable. Soon after, the pilot ordered both anchors to be let go and the main engine to be run at emergency full astern in an attempt to reduce the effects of the impact. At 1442, Crimson Mars grounded on Long Tom Reef and shuddered to a stop as the port anchor was let go and the main engine was run astern.

At 1446, the ship, with its engine running astern, moved off the reef and refloated. The pilot ordered the anchor to be retrieved. This resulted in the failure of the port windlass and the anchor cable running out to its bitter end, which held. The ship remained at anchor off Garden Island until two tugs that had been called to assist were made fast at 1605. The anchor cable was then cut, just above the hawse pipe, by the ship's crew using gas cutting equipment and left in the river together with the port anchor. The ship returned to the Bell Bay anchorage so that an assessment of the damage could be made. No oil spill or other pollution resulted from the incident.

The ship was severely damaged with its bulbous bow holed and pushed in, and ballast water tanks forward were breached. The damage could not be repaired in Bell Bay and over the next few days contingency arrangements were agreed upon by the ship's Flag State, classification society and the Australian Maritime Safety Authority.

On 12 May, with contingency arrangements in place, Crimson Mars sailed for Taiwan to unload its cargo and undergo permanent repairs in dry dock. The ATSB investigation also found that the attempt to retrieve the port anchor and later the cutting of the anchor cable were necessarily hazardous operations. The ship's and the ports procedures for contingency planning and emergency response were considered inadequate. The ATSB has made several safety recommendations 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

The ATSB has found that a lack of passage monitoring resulted in the Vanuatu registered offshore tug/supply ship Massive Tide grounding on Rosemary Island, off Dampier Western Australia, at 0445 on 29 August 2006.

The Australian Transport Safety Bureau investigation found that fatigue probably impaired the performance of both the master and the officer of the watch and that the officer of the watch did not adequately monitor the ships progress during the voyage from the jack-up drill rig Ensco 106 to Dampier on the morning of 29 August.

At 0100 on 29 August, Massive Tide departed the drill rig Ensco 106 at a speed of 9.8 knots and on a heading of 129 degrees, a heading that would take it directly to Rosemary Island, rather than the Dampier Sea Buoy as intended.

At 0200 and 0400, the officer of the watch recorded the ship's GPS position in the deck logbook, but did not plot either position on the navigational chart.

At 0445, Massive Tide grounded on the shoals approaching the western shore of Rosemary Island. The rest of the crew were called out and checks of the ship, its machinery and the surrounding area revealed that no damage or pollution had occurred.

Immediate attempts to refloat the ship were unsuccessful and plans were put in place to try again on the next high tide. At 1035, the ship floated free without assistance.

The ATSB report further concludes that the ship's master did not ensure that the bridge watchkeepers routinely followed his instructions and company procedures; and that the procedures and practices in place on board Massive Tide did not ensure that the levels of watchkeeper fatigue were effectively managed.

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

The ATSB has found that neither the harbour pilot nor the ship's crew adequately considered the ships speed or its movement in the prevailing conditions and this led to the Indian oil tanker Desh Rakshak grounding near Point Lonsdale.

The Australian Transport Safety Bureau investigation found that the depth of water below the ship's keel was less than the bridge team had anticipated; and the Port Phillip Sea Pilots procedures did not give effective guidance to the pilot when deciding whether, or not, to pilot the ship from sea to the Melbourne outer anchorage in the prevailing conditions. It was also found that the inadequate application of bridge resource management led to the ship's bridge team having little effective input during the pilotage passage.

Desh Rakshak arrived off Port Phillip on the morning of 4 January 2006, with about 80 000 tonnes of crude oil cargo on board, and at 0800 a pilot boarded the ship for the transit from sea to the Melbourne outer anchorage.

The pilot planned to enter the port to the west of the track marked by the main leading lights, to keep the ship out of an opposing tidal flow for as long as possible. When the ship was almost abeam of Point Lonsdale Lighthouse, the pilot thought he could see the high and low main leading lights just open to the west. This indicated to him that the ship was on the edge of the Great Ship Channel. However, the ship was further to the west than the pilot thought.

The ship continued the transit and anchored at 1154. No one on board the ship observed anything that might have suggested that the ship had grounded at about 0825, when it was abeam of Point Lonsdale.

At about 1245, the ship's crew discovered that the level in the lower fore peak water ballast tank was rising. An inspection of the tank revealed that the ship's hull had been holed.

The ship berthed in Geelong on 5 January and temporary repairs were carried out before it sailed for Singapore on 19 January, where it was dry-docked for permanent repairs.

The ATSB is pleased to report safety action already taken and has made several safety recommendations with the aim of preventing similar events.

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

The ATSB has found that insufficient train braking and inadequate warning distance contributed to a collision between a track mounted excavator and a freight train at Inverleigh, Victoria on 25 September 2006.

The Australian Transport Safety Bureau investigation established that the collision occurred because the train driver's initial brake applications approaching the work site were too little too late and that the outer flag person protecting the worksite was not positioned far enough away from the site given the anticipated train traffic, the line speed and the descending gradient.

The ATSB concluded that 'in these circumstances there was an unacceptably high risk of a collision'.

The ATSB report makes recommendations to the train operator and the track manager with the aim of protecting track-work sites from similar accidents.

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

The ATSB has been successful in downloading key data from the flight data recorder (FDR) of the Garuda 737 accident aircraft but the cockpit voice recorder (CVR) has not yet been able to be downloaded.

The Australian Transport Safety Bureau (ATSB) is assisting the Indonesian National Transportation Safety Committee (NTSC) with Indonesias investigation into the factors which led to the accident in accordance with Annex 13 to the international Chicago Convention under which the Indonesian NTSC is in charge of the safety investigation and the ATSB is Australia's 'accredited representative'.

In addition to the ATSB's three on-site investigators, as part of this assistance, four specialist ATSB investigators in Canberra have been working since Friday afternoon, together with other staff, to download data from both the CVR and the FDR recovered from the accident aircraft.

The ATSB has been authorised by the NTSC to report that, despite the damage to the two recorder 'black boxes', useful data has been recovered from the FDR. The flight data recording system is designed to record over 200 engineering parameters. The recovered data covers the previous 53 flight hours of aircraft operation, and includes substantial data from the accident flight.

The ATSB has this afternoon provided to the NTSC some initial FDR data including the aircraft's speed, vertical acceleration, flap settings and the wind experienced in the accident sequence.

ATSB investigators have been working with the US-based CVR manufacturer, Honeywell, to download data from the CVR but an ATSB investigator now needs to take the CVR module to Honeywell in Seattle to attempt recovery because all normal specialist recovery techniques have proved unsuccessful.

At the NTSC's request, the ATSB is prepared to continue to analyse the recovered FDR data over the coming weeks and months as the investigation progresses and to prepare a full accident animation.

It is for the NTSC to authorise the release of any information derived from the recordings as it becomes available and is verified by the investigation team.

The ATSB has reviewed safety information on a Qantas 747 tyre burst incident on take-off at Singapore Airport on 8 March 2006 and agrees with the Singapore and German authorities that there was no safety concern warranting a major investigation.

In March 2006, specialist investigators in Australia, Singapore and Germany determined after preliminary investigation that a full investigation was not warranted. From September 2006, the ATSB and Singapore Air Accidents Investigation Branch reviewed detailed material received with the full cooperation of Qantas and again determined a major investigation was not required.

While tyre burst incidents can be potentially very serious, in the Singapore incident the aircraft crew was not aware of any damage to the aircraft as a result of the loss of one of its 18 tyres on take-off until about 6 hours into the flight to Frankfurt when a problem with the number 4 hydraulic system became apparent. The crew managed the problem and landed safely in Frankfurt where the damage to the aircraft wing-to-aircraft body fairing (fibreglass non-structural) outer skin was seen. Repairs were made and appropriate safety authorities notified.

Under international aviation law (the Chicago Convention and its Annex 13) the country of occurrence is responsible for any safety investigation. Singapore assessed that the occurrence was not an accident or serious incident as defined by Annex 13 and decided not to investigate.

Modern passenger aircraft have many redundant safety systems and while damage to the aircraft's fairing may look very worrying to the general public, it was superficial and did not affect the structural integrity of the aircraft. There is also no suggestion of a systemic problem with 747 tyres or the aircraft's hydraulic systems.

The ATSB investigates aircraft accidents and serious incidents in Australia and has to apply judgement as to which of the more than 7000 occurrences reported annually warrant investigation within a budget that allows for about 30 larger and 60 smaller new investigations. Similar judgements are made by other professional investigation bodies around the world.

The ATSB investigates all fatal accidents (except sport aviation) which are overwhelmingly in the general aviation sector and all accidents involving international carriers in Australia. A number of recent ATSB investigations have involved aircraft in the Qantas group, which is in line with Australian passenger airline activity levels.

After further review of the circumstances of the tyre burst, the ATSB agrees with the Singapore authorities that a major investigation would not contribute to future safety in a manner that would be likely to lead to an improvement in 747 or tyre design, manufacture or operations.

The ATSB has found that a Cessna 208 engine failure and forced landing onto a lake in a remote part of south-western Tasmania last year was due to a previous generator failure, has praised the pilots actions in landing the aircraft and ensuring passenger safety, and has made a number of safety recommendations to prevent a similar failure.

The Australian Transport Safety Bureaus final investigation report states that the aircraft, a single engine Cessna 208 floatplane was being operated on a commercial scenic flight over rugged terrain with a pilot and 10 passengers. The occupants were fortunate to escape unharmed, due to the pilots prompt actions in diverting to Lake Burbury when an engine chip-detector warning light came on. Within minutes of the warning light illuminating, the engine failed completely, and the pilot was able to conduct a forced landing onto the lake. The aircraft ended up on a mud bank on the edge of the lake and the occupants were able to walk away unharmed.

A previous generator failure led to electrical discharge damage (EDD) to the engine, resulting in its failure in-flight. EDD is a known problem with the Pratt and Whitney Canada PT-6 series turbo-prop engines fitted to this aircraft type. The ATSB has investigated similar events in Australia previously and the ATSB report cites 43 similar events reported worldwide since 1992. Some of these events have also been investigated by the US National Transportation Safety Board.

As a result of the ATSB investigation into this serious incident, a number of safety actions have been implemented by the aircraft and engine manufacturers as well as Australia's Civil Aviation Safety Authority (CASA). CASA has advised the ATSB that it will issue mandatory aircraft maintenance instructions and Airworthiness Bulletins to reduce the possibility of EDD occurring and will highlight the issue to the Australian aviation industry through its Flight Safety Australia magazine.

While the safety actions of all parties are to be commended, the ATSB remains concerned that there remain safety issues that need to be addressed to eliminate the possibility of EDD events leading to engine failures of this engine type. The ATSB final report therefore contains a number of safety recommendations to the aircraft and engine manufacturer, the Canadian and US airworthiness authorities, Transport Canada and the Federal Aviation Administration and CASA.

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

The ATSB's final aviation investigation report into a fatal fire-bombing accident south of Cootamundra last year found that the pilot lost control of the aircraft during a low altitude turn and that his lack of experience on the modified Dromader turbine-engined aircraft may have been a contributing factor.

The Australian Transport Safety Bureau notes that this was only the second fatal accident involving a fixed-wing aircraft engaged in fire-bombing operations in Australia since they commenced in the early 1960s, despite the high risks associated with that type of flying.

In contrast to frequently experienced severe conditions, this accident on 16 February 2006 occurred in warm to mild weather with good visibility, gentle winds, and over relatively benign terrain.

The deceased pilot was an experienced agricultural pilot with previous fire-bombing experience. Although he had considerable flying experience on radial-engine Dromader aircraft, and in other turbine agricultural aircraft, his total flying experience in the modified turbine Dromader was only 4.7 hours. Prior to commencing duty two days previously, the pilot had not flown firebombing operations for three years.

The report concluded that the pilots limited familiarity with the handling characteristics of the modified and heavily-loaded aircraft might not have allowed adequate recognition of an impending stall. The pilot had not jettisoned the load of retardant and the aircraft stalled while the aircraft was being manoeuvred at a height that did not permit recovery before colliding with the ground. The possibility that the pilot was distracted by either a problem with the operation of the fire doors or some other activity could not be determined.

Subsequently, the State fire authority reviewed the minimum pilot experience levels for aerial fire suppression. That review included more accurately reporting a pilots experience on specific aircraft types to ensure minimum requirements were met prior to being rostered for fire-bombing operations and also introduced minimum recency requirements.

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

The Australian Transport Safety Bureau (ATSB) is inviting owners of flying Amateur-built ABAA and Experimental (ABE) aircraft to participate in a survey. This is the first time in Australia that a constructive effort has been made to gather data on this growing segment of general aviation. ABE aircraft have become an increasingly popular alternative to the purchase of traditional certified aeroplanes. The strong growth in this segment of general aviation deserves greater attention.

This survey was developed with the assistance of members of the ABE aircraft community, and we thank them for helping us to construct this simple but informative survey. In the coming months, the ATSB will collate the survey responses, and using other data held by the Bureau, build a picture of the health of ABE aircraft in Australia. We hope that you will take the time to participate in our survey by sharing your experiences with us.

The survey will take only about 10 minutes to complete. Please complete the survey online or download and print a copy and send it to us, free of charge, using a Reply Paid envelope. Survey closed.

If you have any questions about the survey please contact us in the following ways

Mail: ATSB, Aviation Safety Research
ABE Survey
Reply Paid 967
Civic Square ACT 2608
Phone: 1800 621 372
Email: abe.survey@atsb.gov.au
Fax: 02 6247 3117