An ATSB investigation into a fatal helicopter accident has highlighted the continuing risks facing pilots when flying around powerlines.

On 20 May 2010, a helicopter struck a powerline during forestry spraying operations near the Latrobe Valley Airport in Victoria. The helicopter crashed and the pilot, the only person on board, died.

The ATSB's investigation report, released today, describes how the pilot struck the wire on the final spray run despite being aware of the wire's location.

ATSB Chief Commissioner, Mr Martin Dolan, said this accident is part of a worrying trend in aviation accidents.

"Tragically, pilots continue to die in wirestrike accidents," Mr Dolan said.

"More than 180 wirestrike accidents have been reported to the ATSB over the past 10 years.

"Pilots must always be alert to the risks of flying near wires. Using basic strategies to manage these risks, such as using temporary powerline markers as advised in this report can save pilots' lives."

The ATSB and the Aerial Agriculture Association of Australia recently released an educational booklet on avoiding wirestrikes. The booklet describes recent wirestrike accidents that occurred during spraying activities. More importantly, it provides ways for pilots to minimise the risk of striking a powerline while conducting aerial operations.

Avoidable Accidents booklet: Wirestrikes involving known wires: A manageable aerial agriculture hazard is available on the ATSB website.

Investigation Report: AO-2010-033

Agricultural pilots are being reminded of the dangers associated with flying near wires following the release of an ATSB booklet today.

The booklet, released in association with the Aerial Agriculture Association of Australia, highlights recent wirestrike accidents that occurred while pilots were conducting spraying activities.

Importantly, the report provides ways for pilots to minimise the risk of striking a powerline while conducting aerial operations.

ATSB Manager of Research Investigations, Dr Stuart Godley, said that in the majority of wirestrike accidents the pilots had known of the powerlines before they struck them.

'Typically, pilots have been working around the same wires in the hours before a wirestrike accident,' Dr Godley says.

'Due to a change of spraying plans or a clean-up run once a paddock has been sprayed, the pilot's focus is temporarily shifted away from the task of identifying the location of wires.'

The booklet provides methods for pilots to minimise the risk of striking wires while conducting aerial operations. These are:

• setting client expectations so that they are clear that safety comes first
• conducting an aerial reconnaissance before spraying and extra aerial reconnaissance before the cleanup run
• reassessing the risks when plans change
• avoiding unnecessary distractions and refocussing when distracted
• keeping vigilance limitations in mind
• actively looking for wire
• managing operational pressures including not accepting tasks that are beyond your personal minimums
• having a systematic approach to safely managing wires.

The report also highlights the role of landholders and utility owners in contributing to safety. This includes installing markers on wires, particularly where regular low-level flying takes place.

The booklet Wirestrikes involving known wires: A manageable aerial agriculture hazard is available on the ATSB website.

An interim ATSB investigation report has confirmed the sequence of events that led to the 4 November 2010 uncontained engine failure on board a Qantas A380 aircraft over Batam Island, Indonesia.

The report also sets out how, as a result of the investigation to date, Rolls-Royce, affected airlines and safety regulators have taken action to ensure the continued safe operation of A380 aircraft.

Released today, the report highlights how the intermediate pressure turbine disc in the aircraft's No. 2 engine had been weakened by an oil fire. As a result, the disc separated from its shaft, increased its rotation speed and broke into several parts. Sections of the fractured disc and other engine components penetrated the aircraft's left wing and a number of other areas on the aircraft, resulting in significant structural and systems damage.

The oil fire that weakened the disc was due to a manufacturing defect in an oil feed pipe. That defect resulted in fatigue cracking in the pipe, so that oil sprayed into an engine cavity where it ignited because of the high air temperature.

The report also shows how some of the extensive flight data recovered in the first stage of the investigation has been used to program a simulation of how the aircraft handled following the accident. This has helped investigators to understand better the aircraft's handling and performance.

The simulation was part of a broader exercise to understand the extent and consequences of the airframe and systems damage to the aircraft and the consequences for flight crew workload. The findings from this continuing work will provide valuable safety lessons for future operations.

The ATSB will continue to work with international safety agencies and other organisations to gather and compile the large amount of complex factual information required to complete the investigation. Included in this work will be:

• testing and analysing the black-coloured soot residue found in the left wing fuel tank
• analysing the flight simulation test data
• continuing to review the quality control and quality assurance system affecting the engine design and manufacturing process
• reviewing the aircraft's maintenance, including engine workshop visits.

The aircraft is currently in Singapore awaiting repair.

Given the highly complex nature of this investigation, the final ATSB report is expected to be released in May 2012.

A copy of the interim factual report is available at AO-2010-089

The rate of fatal accidents in general aviation is 3½ times higher than for air transport activity according to an ATSB report.

Released today, the statistical report examines aviation accidents and incidents between 2001 and 2010 across all aviation types in Australia.

During the past ten years, there were 236 people killed in 147 fatal accidents in general aviation. General aviation includes all VH-registered flying activities except scheduled and charter passenger and freight operations.

Within general aviation, private flying accounted for the highest number of fatalities at 135 people between 2001 and 2010.

ATSB Chief Commissioner, Mr Martin Dolan, said anyone involved in general aviation, and private pilots in particular, should take heed of these findings.

"This report is a startling reminder of the dangers facing private pilots and general aviation as a whole," Mr Dolan says. "What's more, many of these tragedies could have been avoided with simple risk management procedures."

Mr Dolan says the ATSB is focussing more effort on targeting general aviation with safety messages due to the high number of accidents in this area.

"We've been preparing a series of publications for general aviation and private pilots," Mr Dolan says. "We have drawn graphic attention to the consequences of doing risky things such as low flying, which has led to a series of fatalities over time.

"We are also assisting private pilots to better assess the set of risks they are facing and how to deal with this risks."

A copy of the statistical report, Aviation Occurrence Statistics, 2001 to 2010 is available on the ATSB website.

Fact sheet

Top five accidents and serious incidents (General Aviation)

1. Terrain collisions (e.g. ground strikes; wirestrikes)
2. Aircraft control (e.g. hard landing; loss of control; unstable approach; wheels-up landing)
3. Powerplant and propulsion (e.g. partial and total power loss; engine failure; propeller failure; transmission and gearbox issues)
4. Aircraft separation (e.g. breakdown of separation; mid-air collision)
5. Runway events (e.g. depart, approach, land wrong runway; runway excursion and incursion; runway undershoot)

Top five accidents and serious incidents (Air transport-fare-paying passenger aircraft)

1. Aircraft separation (e.g. breakdown of separation; mid-air collision)
2. Aircraft control (e.g. hard landing; loss of control; unstable approach; wheels-up landing)
3. Powerplant and propulsion systems (e.g. partial and total power loss; engine failure; propeller issues; transmission and gearbox issues)
4. Miscellaneous events (e.g. crew incapacitation; depressurisation; missing aircraft; security issues; stall warnings; laser-related issues; unauthorised low flying; warning device issues)
5. Terrain collisions (e.g. ground strikes; wirestrikes)

You can also find a range of safety education material under the Publications tab on the ATSB's website at www.atsb.gov.au

ATSB investigations resulted in major improvements to transport safety, according to a new research report.

The report examines safety issues-and resulting actions-identified by the ATSB across the aviation, marine and rail sectors during 2009-10.

From the ATSB's investigations, 124 safety issues (factors that could adversely affect the safety of future operations) were identified. The transport industry undertook 141 separate safety actions to deal with these issues.

Overall, inadequate procedures or the lack of procedures posed the greatest safety risk across all three modes of transport.

ATSB Chief Commissioner, Mr Martin Dolan, said the report shows that industry is actively managing these risks. 

'I'm pleased to see that the aviation, marine and rail industries are actively responding to identified safety issues by improving procedures, documentation and education,' Mr Dolan said.

'By directly dealing with safety concerns, transport operators are helping ensure that accidents and incidents are not repeated.'

Of the 37 more complex aviation safety investigations completed by the ATSB, poor or insufficient procedures were the most common type of safety risk identified. Most of these issues were associated with flight operations.

The ATSB's 10 marine safety investigations found that procedures were the most common safety issues, mostly from the deck operations and navigation/pilotage areas.

The 11 rail safety investigations conducted by the ATSB identified safety practices and procedures as the most common safety issues, with vehicle maintenance and network operations being the areas most associated with significant risks.

A full copy of Safety issues and safety actions identified through ATSB transport safety investigations: 2009-2010 financial year is available on the ATSB website.

A new ATSB investigation bulletin released today highlights five instances of aircraft coming too close to each other.

Two of these occurrences were 'breakdowns of separation,' taking place in airspace under Air Traffic Control, which has carefully defined standards to keep planes a set distance apart.

Several safety actions have come out of these occurrences, including the establishment of an awareness program for Air Traffic Controllers, and a systemic review by Airservices Australia.

Mr Joe Hattley, the ATSB's Assistant General Manager of Aviation Safety Investigations says the investigations bulletin provides a useful resource for the aviation industry to help improve safety.

'The bulletin covers a range of the ATSB's shorter investigations and highlights valuable safety lessons for pilots, operators and safety managers,' Mr Hattley says.

Other investigations covered in the bulletin included a depressurisation event, two instances of total power loss and a situation in which fumes and smoke appeared in a plane's cockpit. As a result of a wirestrike, an aircraft operator is working to put together a database of powerlines.

Released quarterly, the bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken or identified. The bulletin also highlights important safety messages for the broader aviation community, drawing on earlier ATSB investigations and research.

Aviation Short Investigation Bulletin: First Quarter 2011 is available on the ATSB website.

Operators of Robinson R44 helicopters are being advised to inspect the security of their helicopters' hydraulic-boost servos following a fatal accident at Cessnock Aerodrome, NSW.

On 4 February 2011, a Robinson R44 Astro helicopter crashed after part of the aircraft's flight controls separated from the hydraulic-boost system during circuit operations. The pilot survived, but the flight instructor and a passenger died in the accident.

The Australian Transport Safety Bureau's (ATSB's) preliminary factual report, released today, reveals that a bolt securing part of the flight control system had detached, causing loss of control of the helicopter.

The preliminary results of the investigation have prompted the ATSB to urge operators of R44 hydraulic system-equipped helicopters to inspect and test the security of the flight control attachments on their R44 helicopters, paying particular attention to the connections at the top and bottom of the servos.

A hydraulic-boost servo makes it easier for the pilot to handle the flight controls-similar to power steering in a car.

Operators who find anything unusual on inspection of R44 flight controls are asked to contact the ATSB on 1800 020 616.

The investigation is continuing.

The ATSB will release a final investigation report within 12 months.

More information on the investigation is available on the investigation page AO-2011-016.

Ship operators need to ensure that they have an appropriate process in place to properly manage the level of crew fatigue according to the Australian Transport Safety Bureau (ATSB).

The advice is a result of the ATSB's investigation into the 3 April 2010 grounding of Chinese bulk carrier Shen Neng 1 on Douglas Shoal, off the coast of Queensland near Gladstone.

In its final investigation report, released today, the ATSB found that the chief mate was affected by fatigue and this resulted in a decreased level of performance while he was monitoring Shen Neng 1's position. The report found that the ship did not have an effective fatigue management system in place to ensure that the bridge watchkeeper was fit to stand a navigational watch. (A watchkeeper is responsible for navigating the ship).

ATSB Chief Commissioner, Mr Martin Dolan, said Shen Neng 1's grounding provides an important safety lesson for all seagoing vessels.

"Fatigue is one of the key safety risks facing seafarers, and watchkeepers in particular. Failure to manage fatigue can lead to loss of life, damage to property and damage to the environment," Mr Dolan says.

"The ATSB urges ship operators to comply with international requirements that ensure operators properly manage the hours of work and rest of watchkeepers."

The report also identifies several other safety issues relating to the accident:

• The ship's safety management system did not contain procedures or guidance in relation to the proper use of passage plans, including electronic route plans.
• In the 30 minutes leading up to the grounding, there were no visual cues to warn either the chief mate or the seaman on lookout duty, as to the underwater navigation hazards directly ahead of the ship.
• At the time of the grounding, the protections afforded by the requirement for compulsory pilotage and active monitoring of ships by the

Great Barrier Reef and Torres Strait Vessel Traffic Service (REEFVTS) were not in place in the sea area off Gladstone.

The report contains two safety recommendations addressed to Shen Neng 1's management company regarding the safety issues associated with fatigue management and passage planning. The report also acknowledges the safety action taken by the Australian Maritime Safety Authority in relation to the extension of REEFVTS coverage to include the waters off Gladstone.

The final investigation report into the Shen Neng 1 grounding.

The ATSB will conduct an onsite media briefing on its investigation into the 30 March 2011 fatal aircraft accident at Moree, NSW.

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

The ATSB has deployed four investigators, three from Canberra and one from Brisbane, who will arrive at Moree later today. Over the next few days they will examine the wreckage site, interview witnesses and collect maintenance records.

Where: Accident site (Blueberry Road, Moree)

When: 11.00am (AEDT), 1 April 2011

On Thursday 14 April 2011, the Australian Transport Safety Bureau (ATSB) will hold a media briefing to accompany the release of its final investigation report into the 3 April 2010 grounding of Chinese bulk carrier Shen Neng 1 on Douglas Shoal, off the coast of Queensland near Gladstone.

ATSB Chief Commissioner Mr Martin Dolan will present the facts of the investigation and highlight the key safety actions that have occurred to prevent a recurrence.

Where: 62 Northbourne Avenue, Canberra City, ACT
(ATSB Central Office)

Time: 10.30am (AEDT), Thursday 14 April 2011

Copies of the investigation report will be available from 10.30am. An audio recording of the media briefing will be available after midday.