As aerial agriculture pilots prepare for an early spring start to their busiest time of year, a new ATSB report highlights past aviation safety events in the industry.

ATSB's Manager Reporting and Analysis, Dr Stuart Godley said, 'ATSB has been working closely with the Aerial Agricultural Association of Australia (AAAA) to strengthen their long-standing education and training program by using reported incidents and ATSB investigations to identify key learning opportunities for pilots.

'The statistics clearly identify a long-term trend in improving safety in the sector, but both ATSB and AAAA remain committed to improving the safety record even further.

'These statistics should serve as a reminder of the risks these pilots will face during the season that are not present in most other types of flying. Hazards include low-level flying with high workloads and numerous obstacles, in particular powerlines and uneven terrain.

'The good news is that, while these risks are always present, they are generally manageable', said Dr Godley.

The report focuses on aerial application accidents between May 2014 and April 2015 to coincide with the agriculture season in most parts of Australia.

Dr Godley said, 'Wirestrike was the most prevalent type of occurrence with more than half of the total accidents and serious incidents involving a wirestrike'.

Mr Phil Hurst, CEO of the AAAA said, 'We approached ATSB with the idea of producing an annual statement of safety trends in the industry to support aerial application pilots in their ongoing professional development through AAAA’s comprehensive ‘Professional Pilot Program’ and training courses.  

'This report is a very useful addition to the tools available to professional low-level pilots and AAAA thanks ATSB for their practical response in improving access to the valuable safety data they hold.'

There were 13 accidents with one resulting in fatal injury in the preceding 12 months. In total, there were 24 reported accidents and incidents involving aerial agriculture and firefighting operations.

Read the report: Aerial application safety: 2014 to 2015 year in review

A fatal Robinson R44 helicopter accident has prompted the ATSB to recommend safety improvements to helicopter fuel tanks in the United States and Europe.

Four people died in the March 2013 accident at Bulli Tops in New South Wales. The R44 helicopter they were travelling in was engulfed in fire after striking a tree and hitting the ground.

Following this accident, Australia's Civil Aviation Safety Authority, and other international regulators, made it mandatory for R44 helicopter operators to replace the R44's all-aluminium fuel tank with a bladder-type fuel tank.

ATSB Chief Commissioner Martin Dolan said that bladder-type fuel tanks reduce the risk of post‑impact fire in the R44. But the ATSB remains concerned at the risk of post-impact fire in helicopters not fitted with crash-resistant fuel systems.

'We believe the US Federal Aviation Administration (FAA) and the European Aviation Safety Agency (EASA) can help improve the safety of many helicopter pilots and their passengers,' Mr Dolan said.

'We have issued safety recommendations to the FAA and EASA. We ask them to take action to increase the number of crash-resistant fuel systems fitted to existing and newly-manufactured helicopters.

'Under international convention, we would expect to hear from the FAA and EASA about their proposed responses to these recommendations by early September 2015,' Mr Dolan said.

The Bulli Tops accident was similar to other R44 accidents involving fatal post-impact fire that made survivability impossible. In each case, the R44s were fitted with all-aluminium fuel tanks.

Mr Dolan said, 'Statistical analysis of accidents in Australia and the United States over ten years found a higher proportion of post-impact fires involving R44s than for other similar helicopter types.'

The analysis also identified that, despite a 20-year-old requirement for new helicopters to have a crash-resistant fuel system, several helicopter types are being made without such a system. In addition, although modification kits are available for a number of helicopter types, they have not been incorporated in many of the existing civil helicopter fleet.

The ATSB's report into the Bulli Tops accident (AO-2013-055), released today, is available from the ATSB website.

Flying visually in poor visibility continues to be one of the most dangerous forms of flying, as evidenced by a fatal aircraft accident near Mount Hotham, Victoria on 23 October 2013.

An ATSB investigation into the accident found the pilot of a Cessna 182Q aircraft—who was flying visually in an aircraft not approved for 'instrument flight rules'—took off despite poor weather forecast along the planned route.

The ATSB found that the pilot likely encountered reduced visibility due to poor weather, which resulted in the aircraft colliding with Mount Blue Rag, at about 5000 feet (1,524 metres) above mean sea level.

ATSB General Manager of Aviation Safety Investigations, Mr Ian Sangston, said this accident serves as a powerful and tragic reminder to visual flight rules pilots of the dangers of flying in poor visibility conditions.

"Between 1993 and 2013 there were 11 accidents involving inadvertent visual flight into 'instrument meteorological conditions', such as poor weather or cloud," Mr Sangston said.

“While meteorological forecasts are inevitably set in terms of the likelihood of low cloud, rain or fog affecting a flight, it is the responsibility of pilots to analyse the risk and make appropriate decisions.”

"In forecast marginal weather, this involves considering alternative options such as diverting or turning back."

"It is important, also, for pilots and others involved in the operation of aircraft to actively support safety-first pilot decision-making."

"Pressing on into poor visibility conditions with no instrument rating, and/or in an inappropriately‑instrumented aircraft, carries a significant risk of severe spatial disorientation due to powerful and misleading orientation sensations."

"This tragic accident was avoidable. It's both sad and frustrating that we continue to investigate accidents where visual flight rules pilots push the limits when flying with poor visibility." Mr Sangston said.

Read the full investigation report AO-2013-186.

An important safety message

Flying with reduced visual cues is one of the ATSB’s top safety concerns.

Under visual flight rules (VFR), it is crucial pilots have sufficient visual reference to see and avoid obstacles and be able to navigate their aircraft. Visual cues are also required to maintain orientation so VFR pilots know which way is up and can maintain control of their aircraft.

This accident highlights the risks associated with operating under the VFR in adverse weather, particularly when flying in a challenging environment such as in mountainous terrain.

Thorough pre-flight planning is essential for avoiding weather. It is not only important to obtain the relevant weather forecasts to develop a mental picture of the conditions that may be encountered, but also to assess this information and understand how it relates to the planned flight. In forecast marginal weather, this involves consideration of alternative options such as delaying, diverting or turning back and pilots assessing their skills and/or aircraft’s suitability for the task in the conditions. 

During flight, pilots must continuously assess the weather for conditions that may adversely affect the safety of the flight and be prepared to use an alternative course of action if conditions deteriorate. This can include seeking assistance, such as that available from air traffic control.

The ATSB is concerned about the frequency of accidents—many fatal—that involve pilots flying with reduced visual cues. This has been highlighted as part of the ATSB's SafetyWatch initiative.

More information on flying with reduced visual cues.

Flying at night in remote areas without sufficient visual cues continues to be one of the most dangerous forms of flying, as evidenced by a recent fatal accident in Western Australia’s Kimberley region.

An ATSB investigation into the accident found the pilot of an R22 helicopter, who did not hold a night visual flight rules (VFR) rating or instrument rating, continued flying after last light to try to reach Springvale station.

The lack of local ground lighting on a moonless night meant the pilot had no visual cues to know exactly where the   helicopter was going or reliably control its attitude, and collided with terrain 46km short of the intended destination.

Night flying continues to pose a high risk for many pilots, particularly those in remote areas where there is little to no ground lighting. On average there are two accidents a year that occur from visual flight at night.

“We continue to be concerned about the frequency of accidents – many fatal – that involve pilots flying with reduced visual cues,” said ATSB Chief Commissioner Martin Dolan.

“Based on research from other countries, accidents at night tend to be unforgiving and more likely to lead to death.”

In the 20 years between 1993 and 2012 there were 26 accidents in Australia that occurred in visual (night) conditions. There were also another 10 accidents involving inadvertent VFR flight into 'instrument meteorological conditions', such as poor weather or cloud. Those 36 accidents resulted in 58 deaths. Nearly all of the accidents occurred on dark nights.

“This fatal accident in the Kimberley highlights the inherent high risk of night flying in remote areas,” Mr Dolan said.

For pilots, the ATSB’s message is simple.

“Day VFR pilots need to plan to arrive at their destination at least 10 minutes before last light and to have a realistic ‘Plan B’ to use when it becomes apparent that an intended flight cannot be completed in daylight,” Mr Dolan said.

“It is important, also, for operators and others involved in the operation of aircraft to actively support safety-first pilot decision-making.”

An important safety message

Flying with reduced visual cues is one of the ATSB’s nine SafetyWatch priorities.

Under visual flight rules (VFR), it is crucial pilots have sufficient visual reference to see and avoid obstacles. Visual cues are also required to maintain orientation so VFR pilots know which way is up and can maintain control of their aircraft. There are often less visual cues at night, even though visibility may be good.

More information on flying with reduced visual cues can be found at: www.atsb.gov.au/safetywatch

Read the ATSB investigation report AO-2014-144

ATSB begins action on Canadian review

The ATSB has today begun action in responding to the Transportation Safety Board of Canada (TSB) review into the ATSB’s methodologies and processes.

Released last week, the review found that the ATSB’s investigation methodologies and practices generally met or exceeded international best-practice standards.

The review also highlighted potential improvements, particularly about the way in which ATSB methodologies were applied in the investigation into the ditching of the Pel-Air Westwind Aircraft off Norfolk Island in November 2009.

In response to the TSB review, the ATSB Commission has decided to reopen its investigation into the Pel-Air accident. A new investigation team will review the original investigation and associated report in the light of any fresh evidence and relevant points raised in the TSB review and other recent aviation reviews.

At the same time, the ATSB Commission will continue to methodically and carefully work its way through the broader findings and recommendations of the TSB review, with the aim of ongoing improvements to the future work of the ATSB.

The ATSB will provide regular public updates on the progress with the re-opened Pel-Air review and with its broader consideration of, and response to, the TSB review.

Transport safety investigators from the Asia Pacific region have converged on Canberra this week to learn about how human factors influence accidents.

The 32 participants from five nations will attend lectures and participate in exercises conducted by the Australian Transport Safety Bureau and featuring leading experts in the science.

Course convenor Dr Richard Batt, the ATSB’s Director International, said human factors were a predominant factor in accidents.

“Research shows 80 to 90 per cent of accidents have a human factor involved,” Dr Batt said.

“This can range from things like operator fatigue, stress, workload, or a lack of crew coordination. These are things that affect performance. Human factors is the second part of the accident enquiry. The ‘what happened’ is the technical aspect, while we look at the ‘why factor’.

Regarded as a science in its own right, human factors is used by all major transport nations in accident investigations.

As part of its regional engagement, the ATSB  makes the course available to countries that  are developing a capacity to investigate human factors, or those that want to update their knowledge base.

The overseas nations represented include Taiwan, Cambodia, Malaysia and New Zealand. The course has also attracted accident investigation managers from several Australian airlines (Virgin, QANTAS, Tiger), the Royal Australian Navy, Royal Australian Air Force, Careflight, Melbourne Airport, Queensland Rail and the University of South Australia.

The ATSB, which investigates major aviation, marine and rail accidents, has three human factors investigators in its team, and gives all of its investigators basic human factors awareness training.

From humble beginnings in 1983, the ATSB’s expertise in human factors is recognised around the world. So popular is the course that bookings are already being taken for 2016.

“The ATSB is a centre of excellence in applying technical analysis and human factors to accident investigation and safety,” Dr Batt said. "These are two fundamental strands to a comprehensive transport safety investigation."

“Some of the techniques identified in human factors in transport safety filter through to other industries,” said Dr Batt. “What began as crew resource management in aviation is now applied as team resource management in other sectors.”

MEDIA OPPORTUNITY

• Graduation of course participants
• ATSB Chief Commissioner Martin Dolan, course convenor Dr Richard Batt and participants available for interview
• Friday 21 November, 12.15pm, Crowne Plaza, 1 Binara Street, CANBERRA  ACT

Australia’s transport industries are some of the safest in the world but more can be done to improve safety, according to the ATSB’s annual report.

Approved for tabling by the Deputy Prime Minister the Hon Warren Truss, the annual report highlights the ATSB’s top transport safety concerns across the aviation, maritime and rail industries.

ATSB Chief Commissioner Martin Dolan said the safety concerns bring together the ATSB’s investigation findings and analysis of the safety occurrence data reported by industry.

“We are urging industry to give heightened attention to the risk areas identified by the ATSB,” Mr Dolan said. “While we are seeing improvements in certain areas of transport safety, other risk areas remain a concern to the ATSB. We’ll continue to closely monitor these transport safety hotspots over the coming year.”

One of the year’s notable transport safety achievements was the nation-wide fit out of the bladder-type fuel tank on all Robinson R44 helicopters (in accordance with the manufacturer’s directive). The bladder tank replaced the rigid aluminium fuel tank that was highly susceptible to post-impact fires. 

The ATSB’s growing concern about accidents caused by flying with reduced visual references, such as in cloud or at night, has led to that matter being included as a top transport safety risk area identified in the ATSB’s safety priorities.

“We’ve moved to address concerns about the increasing number of accidents caused by flying with reduced visual references,” Mr Dolan said. “By highlighting these priorities to visual flight rules pilots, we aim to make them more aware of the risks and of what can be done to avoid what can be catastrophic mistakes while flying.”

Three significant investigations into flying with reduced visual cues are included in the annual report, along with features on some of the 217 investigations conducted by the ATSB in 2013–14.

The annual report also details the ATSB’s involvement as the lead organisation in the search for missing Malaysia Airlines flight MH370 that disappeared in March 2014. “Finding the missing aircraft and helping solve the mystery of its disappearance is our greatest challenge. Just as importantly, though, we continue our work to improve safety through investigating aviation, maritime and rail incidents at home,” Mr Dolan said.

Australia’s current top transport safety priorities across aviation, maritime and rail (SafetyWatch):

1. Flying with reduced visual cues
2. Marine work practices
3. Safe work on rail
4. Data input areas for aviation
5. Safety around non-controlled aerodromes
6. General aviation pilot risks
7. Maritime pilotage
8. Under reporting of occurrences
9. Handling approach to land

More information on these risk areas can be found at the ATSB’s SafetyWatch web page www.atsb.gov.au/safetywatch

Download: ATSB Annual report 2013-14

The ATSB will today conduct an onsite media briefing on its investigation into the 14 October 2014 aircraft accident of a Van’s RV-6A, at Chelsea, Melbourne, Victoria.

The Investigator-in-Charge will discuss factual information known to the ATSB at this time and will outline the investigation process.

The ATSB has deployed three investigators, who have already begun work at the accident site. Over the next few days they will examine the wreckage site, interview witnesses and collect maintenance records.

The investigators are seeking witness reports as well as video or imagery that might assist the investigation. Witnesses can call the ATSB on 1800 020 616.

Where: Camp Street, Chelsea, Vic.

When: 1:00 PM AEDT, 15 October 2014

The ATSB is urging pilots of single-engine aircraft to plan for partial power loss, following the release of a new educational video.

Between 2000 and 2010, there were nine fatal accidents resulting in 20 people losing their lives as a result of a response to a partial power loss soon after take-off. Importantly, there were no fatal accidents where the engine initially completely failed.

ATSB research manager Dr Stuart Godley says the high number of fatalities and serious injuries resulting from partial power loss should be of concern to pilots and flight instructors.

“Historically, the simulated total loss of power and subsequent practice forced landing has been the core of a pilot’s emergency training,” Dr Godley says. “However, our accident data shows that for single engine aircraft, a partial power loss during and after take-off is three times more likely to occur than a complete engine failure.”

While partial power loss can be more challenging to manage—due to the number of choices and decisions confronting the pilot—Dr Godley says that the lack of training, coupled with the lack of pilot preparation and planning, may also help explain the higher number of fatalities.

“Total engine failure after take-off is part of the Day VFR syllabus and is taught and practiced throughout a pilot’s initial training. However, partial power loss after take-off is not a practiced syllabus item and probably does not receive the same emphasis during training.

“A pre-flight briefing for both a complete engine failure and partial power loss is the key to a pilot maintaining control of their aircraft.” says Dr Godley.

The new short video, available on the ATSB’s YouTube channe(Opens in a new tab/window)l (ATSBinfo) provides pilots and flight instructors advice on how to manage the dangers surrounding partial power loss in single engine aircraft.

More information about managing partial power loss in single-engine aircraft is also available in the ATSB’s avoidable accident booklet, Managing partial power loss after take-off in single-engine aircraft.

The ATSB today released a request for tender to acquire the services of a specialist company capable of conducting a deep-water search under ATSB direction for missing Malaysia Airlines Flight MH370.

Engaged as a prime contractor, the company will provide the expertise, equipment and vessel(s) necessary to undertake an intensified underwater search for the missing Boeing 777 aircraft in the defined zone in the southern Indian Ocean.

While the precise search zone is currently being established by an international search strategy working group, it is expected that the successful tenderer will search an area up to 60,000 square kilometres based on the 'seventh handshake' arc where the aircraft last communicated with the Inmarsat satellite. Definition of the search zone will be finalised within two to three weeks.

The successful tenderer will localise, positively identify and map the debris field of MH370 using specialist equipment such as towed and autonomous underwater vehicles with mounted sonar and/or optical imaging systems.

The intensified search will begin in August 2014 and is expected to take up to 12 months, depending on weather conditions. The successful tenderer will use the data from a bathymetric survey (already underway) to navigate the search zone, which has water depth between 1000 and 6000 metres.

The search vessel(s) used by the prime contractor may also be coordinated with other vessels also undertaking search activities in the search zone on behalf of other countries.

A copy of the request for tender is available on the AusTender website at www.tenders.gov.au(Opens in a new tab/window). Request for tender submissions are due by 5.30pm AEST on 30 June 2014. 

At the request of the Malaysian Government, the ATSB is leading the search for missing Malaysia Airlines Flight MH370.

All enquiries relating to the tender: opsearch@atsb.gov.au