The importance of maintaining situational awareness and the risks of pilot distraction are two of the major safety lessons featured in the latest edition of the ATSB's investigation bulletin, released today.

Situational awareness was a factor in air proximity events, breakdowns of separation, ground handling and wirestrikes. An example of a situational awareness issue occurred when a Pilatus PC-12/45 and Aeronautica MacchiAL60 passed within close proximity to each other while flying. This incident highlighted the need for aircrew to conduct diligent radio broadcasts and continual visual scanning to minimise the risk of collision.

The bulletin also identified how pilot distractions can affect the safety of aircraft operations. This was highlighted when the pilot of a Cessna 206 was distracted by other traffic operating in the area and consequently did not change the fuel tank selection. This resulted in an engine failure and subsequent forced landing.

Other safety lessons featured in the bulletin cover:

• the importance of pilots using all available resources to confirm clearances from the air traffic control
• the importance of not over-extending an aircraft glide after an engine failure
• the difficulties associated with managing an in-flight engine failure at low altitude
• the steps pilots can take to avoid wirestrikes, especially when flying in unfamiliar areas
• the techniques pilots can use to maintain separation from other aircraft.

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.

A copy of the Level 5 factual investigations: 1 October 2010 to 31 December 2010 bulletin.

Aircraft take-off performance errors resulting from simple human data calculation or entry occur too frequently but can be avoided or detected, according to an ATSB research report, released today.

The report examines Australian and international occurrences between 1 January 1989 and 30 June 2009 that involved the calculation and entry of erroneous take-off data. It reveals that take-off errors happen for many different reasons such as the wrong figure being used as well as data being entered incorrectly, not being updated, or being excluded.

Importantly, the report identifies that while no one is immune from these types of events, risk can be dramatically reduced through good operating procedures, aircraft automation systems and software design, and clear and complete flight documentation.

The consequences of these sorts of errors can range from aborted take-offs through the tail of the aircraft scraping the runway and, in the extreme, collisions with the ground.

ATSB Chief Commissioner, Mr Martin Dolan, said that while there is no single solution to preventing take-off performance calculation and entry errors, good operating procedures will help to mitigate the risks associated with these errors.

'With each operator using different take-off calculation methods on different types of aircraft, there will never be one solution for eliminating these errors,' Mr Dolan said.

'Good standard operating procedures, such as cross checking all take-off calculations or verifying data using multiple sources, will help detect any errors before the aircraft leaves the gate.'

'We advise operators to consider all the possible errors that could be introduced and then determine if the procedures in place will prevent these errors from occurring or provide opportunity to be detected.'

This ATSB research report expands on previous research by the Laboratory of Applied Anthropology, Boeing and Airbus by providing both an Australian and international perspective on these events. The report also explores why these events occurred by analysing the contributing safety factors.

A copy of the research report, Take-off performance calculation and entry errors: A global perspective, is available on the ATSB website at www.atsb.gov.au

The Australian Transport Safety Bureau (ATSB) is urging shipping operators to regularly check and replace their container lashing equipment as a result of an incident involving the Hong Kong registered container ship Pacific Adventurer.

On 11 March 2009, Pacific Adventurer lost 31 containers overboard during severe weather and large swells off Cape Moreton, Queensland. As the unsecured containers went overboard, they holed two of the ship's fuel oil bunker tanks. This caused the ship to leak 270 tonnes of bunker oil into the sea which affected 70kms of Queensland's coastline.

The ATSB investigation into the incident found that much of the ship's loose and fixed container lashing equipment, which is meant to secure the containers to the ship, was in poor condition. In addition, the inspection and replacement regime of this equipment had not been effectively implemented.

ATSB Chief Commissioner, Mr Martin Dolan, said this incident highlights the importance for all operators to ensure their cargo is properly secured, especially before bad weather is expected.

'Unsecure shipping containers pose a major threat to life, property and the environment,' Mr Dolan said.

'All shipping operators should be regularly and systematically maintaining their lashing equipment to prevent a recurrence of the Pacific Adventurer incident.'

The ATSB also identified several other safety issues as a result of the investigation. These include:

• there was no requirement for a third party to inspect this lashing equipment
• the cargo in the containers lost overboard was not packaged in accordance with international dangerous goods shipping requirements
• the dangerous goods shipping compliance audit regime did not pick up on this fact.

The organisations involved have already addressed these issues.

A copy of the Pacific Adventurer investigation report MO-2009-002.

The Papua New Guinea Accident Investigation Commission (AIC) has distributed to directly involved parties a draft report of its investigation into the accident that occurred near Kokoda, Papua New Guinea on 11 August 2009. Directly involved parties are those who were directly involved in the accident or who may have influenced the circumstances that led to it.

Those parties have until 23 January 2011 to comment on the factual accuracy of the report and to provide additional evidence in support of any comments.

The AIC is investigating this accident in accordance with Annex 13 to the Convention on International Civil Aviation. The Australian Transport Safety Bureau (ATSB) has assisted the AIC investigation by providing investigator support, technical advice and facilities support.

It is anticipated that the AIC will release its final investigation report to the public in the first quarter of 2011.

The ATSB is distributing this media release with the permission of the Papua New Guinea Accident Investigation Commission.

Media enquiries about the AIC report and ongoing investigation should be directed to:
Mr David Inau
CEO
Papua New Guinea Accident Investigation Commission
Telephone: +675 325 7500 or +675 311 2406, ext 614
Email: dinau@transport.gov.pg

The Australian Transport Safety Bureau (ATSB) will undertake a systemic safety investigation into Queensland's coastal pilotage operations. This follows the ATSB's investigation into the 7 February 2009 grounding of the tanker Atlantic Blue in the Torres Strait.

ATSB Chief Commissioner, Mr Martin Dolan, said the ATSB decided to conduct this broader safety investigation to address information that came to light during the Atlantic Blue investigation as well as earlier, similar investigations.

"The Atlantic Blue investigation is one in a number of cases where we received reports from coastal pilots raising concerns about the safety of coastal pilotage operations," Mr Dolan said.

"Our systemic safety investigation will take around 12 months to complete. During this time, we'll gather information from pilots, pilotage providers, regulators and other stakeholders and analyse that information to see if any steps can be taken to enhance the safety of the pilotage system."

The investigation into the grounding found that Atlantic Blue's bridge team had not effectively monitored the ship's progress in the shipping route. In particular, there was no allowance for the prevailing strong wind and tidal stream. This resulted in the ship deviating from its planned track. Subsequent adjustments to the course were inadequate and could not prevent it grounding off Kirkcaldie Reef.

Atlantic Blue's hull remained intact, there was no pollution and the ship refloated on the next flood tide. Following an inspection, authorities permitted the ship to continue its voyage to Townsville.

The investigation report, released today, identifies safety issues in relation to the:

• shipboard safety management system procedures for passage planning
• assessment and audit system to check how coastal pilots carry out pilotages
• traffic monitoring system of the coastal vessel traffic service.

The relevant parties have taken or have proposed safety actions to address all of these issues.

An electrical systems failure onboard a Boeing 747 aircraft near Bangkok, Thailand has prompted extensive safety actions from Qantas, Boeing and the US Federal Aviation Administration.

On 7 January 2008, the aircraft lost electrical power to many of its onboard systems as a result of overflowing drain water entering generator control units that control the distribution of electrical power.

In response to the event and the ATSB investigation, Qantas, Boeing and the US Federal Aviation Administration (FAA) have implemented a number of safety actions to prevent a recurrence. These actions include reinforcing protective 'dripshields' above electrical equipment, improving maintenance practices and pilot training and installing advanced standby flight instruments to Qantas 747 aircraft.

In addition, the generator control unit manufacturer, Hamilton Sundstrand, has increased its monitoring of returned units for signs of liquid contamination.

Despite these safety actions, the ATSB found that the FAA's regulatory and guidance information does not fully address the potential harm to flight safety posed by liquid contamination of electrical system units in transport aircraft. As well, the information provided to 747-400 flight crews regarding standby power operations is limited. The ATSB has made recommendations to the US FAA and Boeing to address those safety issues.

The ATSB has also released a Safety Advisory Notice reminding operators and flight crews about the need to respond immediately to battery discharge alerts.

The ATSB investigation report, released today, describes how three of the aircraft's four main electrical power supplies stopped operating after water entered three of the aircraft's generator control units. A drain line heater had failed, causing an ice blockage which led to the drain line overflowing in the galley. The water flowed through a gap in the aircraft's floor, then through a dripshield and into the generator control unit.

This affected cabin lighting and many of the aircraft's communication, navigation, instrumentation and flight guidance systems, including the autopilot. Many aircraft systems were subsequently powered by the aircraft's emergency batteries.

The aircraft's engines, hydraulic system, and pneumatic systems were largely unaffected, and it landed safely at Bangkok shortly afterwards. None of the 346 passengers and 19 crew were injured.

In a preliminary investigation report released today, the ATSB outlines safety actions that have already been taken in response to an uncontained engine failure on board a Qantas A380 aircraft over Batam Island, Indonesia on 4 November 2010.

"The investigation highlights Australian and international cooperation in the interests of aviation safety," said the ATSB's Chief Commissioner, Martin Dolan. "The ATSB is the lead investigator, but many others are involved, and their cooperation has been essential".

"We're still in the early stages of investigation," Mr Dolan added, "but significant action has already been taken to minimise the risk of a recurrence".

The report identifies an overspeed-related failure in the intermediate pressure turbine disc in the aircraft's No 2 engine. 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 to the aircraft.

As a result of the investigation, the ATSB has issued a safety recommendation about potential engine problems in some Airbus A380 aircraft. The problem relates to a possible manufacturing issue with the high pressure/intermediate pressure (HP/IP) bearing structure oil pipes of some engines, which could lead to fatigue cracking, oil leakage and potential engine failure from an oil fire within the HP/IP bearing buffer space.

In response to the recommendation Rolls Royce, affected airlines and safety regulators have taken action to ensure the continued safe operation of A380 aircraft. The action involves the close inspection of affected engines and the removal from service of any engine which displays the suspected problem. In addition, the European Aviation Safety Agency has approved a modification to the engine control software to reduce the risk of an overspeed-related turbine disc failure.

In Australia, Qantas is carrying out the necessary inspections in coordination with the Civil Aviation Safety Authority.

"We stress that this is a preliminary report," Mr Dolan said. "It is intended to set out the sequence of events as we understand it so far and to highlight the safety issue we have identified. A comprehensive report will be completed within a year of the occurrence."

The report also describes the flight crew's actions in dealing with the consequences of engine failure and in landing the aircraft safely in Singapore without injury to any of the 469 crew and passengers on board.

The ATSB's preliminary factual report outlines a number of areas for further investigation. They include additional examination of the turbine disc and other engine components, onboard recorded information, damage to the aircraft and its systems, and of the response by flight, cabin and emergency services crews.

A copy of the preliminary factual report is available on the ATSB website at: AO-2010-089

The ATSB has issued a safety recommendation about potential engine problems in some Airbus A380 aircraft.

The safety recommendation identifies a potential manufacturing defect with an oil tube connection to the high-pressure (HP)/intermediate-pressure (IP) bearing structure of the Trent 900 engine installed in some A380 aircraft.

The problem relates to the potential for misaligned oil pipe counter-boring, which could lead to fatigue cracking, oil leakage and potential engine failure from an oil fire within the HP/IP bearing buffer space.

In response to the recommendation Rolls Royce, affected airlines and safety regulators are taking action to ensure the continued safe operation of A380 aircraft. The action involves the close inspection of affected engines and the removal from service of any engine which displays the suspected counter-boring problem.

The ATSB will hold a media briefing tomorrow (Friday 3 December 2010) at 10.30am to accompany the release of its preliminary factual investigation report into the QF32 occurrence. ATSB Chief Commissioner Mr Martin Dolan will present the known facts gathered from the investigation and highlight the key safety issues that have resulted from the investigation to date.

The full safety recommendation is available via the ATSB website at www.atsb.gov.au.

On Friday 3 December 2010, the Australian Transport Safety Bureau (ATSB) will hold a media briefing to accompany the release of its preliminary factual investigation report into the 4 November 2010 engine failure onboard Qantas Flight QF32 over Batam Island, Indonesia.

ATSB Chief Commissioner Mr Martin Dolan will present the facts gathered from the investigation to date and highlight the key safety actions relevant parties have taken to prevent a recurrence.

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

Time: 10.30am (AEDT), Friday 3 December 2010

The report will be available at the briefing and on the ATSB website from 10.30am. An audio recording of the media briefing will also be available on the ATSB website after midday 3 December 2010.

The ATSB is reminding aerial work pilots to manage their fatigue levels as they take on higher workloads during this time of the year.

The ATSB's advice follows an incident where a pilot fell asleep while undertaking locust spotting activities and had to be awoken by an observer on the plane.

ATSB Chief Commissioner, Mr Martin Dolan, said aerial work pilots are especially prone to becoming fatigued during this time of the year.

"As pilots increase their flying hours doing high intensity agricultural activity, such as spotting and spraying, they are at far greater risk of becoming fatigued," Mr Dolan said.

"Pilots need to make fatigue management an absolute priority to ensure they stay safe while flying."

The ATSB has issued a safety alert that provides advice for pilots to avoid and manage fatigue. The safety alert is available on the ATSB website at www.atsb.gov.au