The ATSB has released a further Interim Factual Investigation Report into the Lockhart River accident on 7 May 2005 in which both pilots and all 13 passengers perished and says that it expects to complete its draft final report by the end of November.

This is the third factual report issued by the Australian Transport Safety Bureau since the tragic accident and, in accordance with international convention, it contains no analysis. The ATSB has previously issued a number of safety recommendations arising from the accident and others will be considered ahead of the final report if or as needed.

The ATSB is today also issuing research papers providing data on fatal accidents in Far North Queensland compared with other regions and on surveyed pilot perceptions of difficulties with the type of approach made in the bad weather of the accident flight.

This Interim Factual report also includes additional information relating to wreckage and the aircraft, the flight data recorder factual report, and a summary of survey and other research dealing with area navigation global satellite positioning system (RNAV (GNSS)) approaches.

The investigation is continuing and in addition to drafting of the final report - which will contain detailed analysis - will include further work on: the operator's management processes, standard operating procedures, flight crew training and checking, and document control; regulatory oversight of the operator's activities, including approvals and surveillance undertaken; the design and chart presentation of RNAV (GNSS) approaches; and desired action to enhance future safety.

The ATSB expects to complete a draft final report by the end of November 2006. To ensure factual accuracy and natural justice, directly involved parties in Australia and internationally will have 60 days to comment on this confidential draft. Contingent on the extent and timing of comments received, the ATSB plans to release its final report to the public in March 2007 after advance notice is given to the families of the deceased.

While the long-time taken for the investigation is regretted, the Bureau seeks understanding on this because it is Australia's worst civil aviation accident since 1968 and, in addition to the destruction of the aircraft, the investigation team does not have the benefit of a cockpit voice recording, survivors, or witnesses. For the sake of those who lost their lives and their friends and loved ones, and in the interest of future safety, the ATSB wishes to undertake as thorough an investigation as possible in the circumstances.

Copies of the latest Interim factual Aviation Safety Investigation Report 200501977 can be downloaded from the website.

An Australian Transport Safety Bureau (ATSB) investigation found that the collision between the Australian registered tug Tom Tough and the Panamanian registered bulk carrier Global Peace resulted in a spill of approximately 25 cubic metres of oil in Gladstone Harbour on 24 January 2006.

At about 2130 on the evening of 24 January, Global Peace entered Gladstone harbour for the transit to the Clinton Coal Terminal. The plan was for the ship to berth at Clinton number three berth with the assistance of three z-peller tugs.

As the ship was approaching the berth, the pilot asked all three tugs to stop pushing and to lay alongside. The master of the aft tug, Tom Tough, laid the tug alongside the ship, with the tug at an angle of about 15 degrees to the ship's side. The tugs bow was in line with the front of the ships accommodation.

At about 2354, Tom Toughs starboard main engine unexpectedly shutdown. The tug's stern swung sharply to starboard and the starboard quarter made heavy contact with the side of the ship, piercing the ship's shell plating.

The tug had punctured the ship's port heavy fuel oil tank. Oil immediately began to flow into the harbour. The flow of oil continued for about 45 minutes.

According to the ATSB investigation report, a cracked starboard main engine clutch oil pipe resulted in the tug's clutch system being emptied of oil. The resultant loss of system pressure activated the main engine shutdown.

The report concludes that the tug's procedures and associated risk analysis had not adequately addressed the risks associated with the engineer spending protracted periods of time out of the engine room, the engine room alarm and monitoring system did not adequately alert the tug master to the engine shutdown, and the towage company had given little thought to the possibility of further fatigue related failures after the failure of the clutch oil pump discharge pipe fitted to the port main engine in February 2002.

The investigation also found that the tugs aft fender arrangement did not provide adequate protection to the tug or the ship and that the ship's port deep fuel oil tank was not protected from a collision.

The ATSB found that the towage company had no system of professional development in place to ensure the ongoing training and performance monitoring of tug masters.

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

An ATSB discussion paper has found that from 1990 to 2005 Queensland had a higher fatal aviation accident rate than the rest of Australia but that the results for Tasmania were much worse, and that the fatal accident rate for Far North Queensland was better than for Queensland's North and Central regions.

Like NSW/ACT, QLD was the location for 102 of the 318 fatal accidents in Australia from 1990 to 2005.

Compared with the national rate of 0.7 fatal accidents per 100,000 landings 1990-2004, TAS had 1.8 and QLD the next highest at 0.9. QLD had 32% of the accidents and 24% of the landings so its rate was higher than the rest of Australia.

The Australian Transport Safety Bureau initiated a research project to see if Far North Queensland (FNQ), where the 15-fatality Lockhart River accident occurred in 2005, was over-represented in longer term accident data and has found mixed results.

Using Australian Bureau of Statistics definitions for the regions, the ATSB found that the fatal accident rate for the South region was 0.7 per 100,000 landings, the same as the national average, but Far North Queensland was 1.0 and both Central and North 1.2.

However, in Far North Queensland 50 per cent of the fatal accidents involved Charter operations and because more passengers were on board, FNQ had the highest fatality rate among Queensland regions.

The ATSB noted a number of limitations with the data including that the location of the accident may have no safety significance. For example, the so called 'ghost flight' involving a chartered Beech King Air in 2000 travelled from southern WA across the NT before running out of fuel and crashing near Burketown, QLD with 8 fatalities.

The ATSB Research Discussion paper also notes the influence of weather, geography and other physical and environmental factors and makes some comparisons among regions in QLD and WA.

Copies of Discussion Paper B2006/0034 can be downloaded from the website, or obtained from the ATSB by telephoning (02) 6274 6425 or 1800 020 616 and comments addressed to the Deputy Director, Information & Investigations by 3 October are welcome.

An ATSB discussion paper has found from a large survey of endorsed pilots that a recently introduced type of satellite approach [termed RNAV (GNSS)] used during the May 2005 fatal accident near Lockhart River is perceived as difficult, particularly in bad weather and without automation and vertical guidance instruments.

The Australian Transport Safety Bureau sent the survey to all Australian pilots with Area Navigation (RNAV) Global Navigation Satellite System (GNSS) endorsement and received 748 representative responses, a response rate of 22 per cent.

The most difficult RNAV (GNSS) approaches reported by pilots, based on responses adjusted by commercial movements into an aerodrome, were Mt Hotham and Lockhart River.

Pilot workload, including time pressure, was perceived as higher for RNAV (GNSS) approaches, and pilots reported having trouble maintaining situational awareness more often than other approaches, except non-directional beacon (NDB). Poor weather and turbulence were among the largest compounding factors. Responses from high-capacity airline pilots differed somewhat and were generally more favourable towards RNAV (GNSS) approaches because their aircraft had autopilots and vertical guidance systems.

Pilots reported a common concern that RNAV (GNSS) approaches did not use distance to the missed approach point references on the approach chart or electronic displays. As with the Lockhart River runway 12 approach, short and irregular segment distances and multiple minimum segment altitude steps were also a concern, as was approach chart interpretability and the use of 5 letter waypoint names with only the last letter differing.

The most common problem trainees had with RNAV (GNSS) approaches was maintaining situational awareness, often linked to confusion as to the segment they were in and distance from runway threshold. Global positioning system (GPS) and waypoint issues were also significant.

49 respondents reported incidents with RNAV (GNSS) approaches: 15 had descended too early due to position misinterpretation and 3 almost did; 5 others lost situational awareness; and 4 descended below the constant angle approach and/or minimum segment steps.

Copies of Research Discussion Paper B2005/0342 can be downloaded from the website, 1800 020 616 and comments addressed to the Deputy Director, Information & Investigations by 3 October are welcome.

An ATSB investigation has found that high track temperatures, track stability and the movement of rolling stock led to derailments involving Train 6MP4 at Koolyanobbing WA and Train 6SP5 at Booraan WA on the afternoon of 30 January 2005.

Koolyanobbing and Booraan are respectively about 200 kilometres and 360 kilometres west of Kalgoorlie. Both freight trains had been travelling to Perth on the Defined Interstate Rail Network (DIRN), 6MP4 having started its journey in Melbourne and 6SP5 in Sydney.

There were no serious injuries due to either derailment but many wagons from each train sustained extensive damage.

The Australian Transport Safety Bureau investigation determined that the most probable cause for each derailment was track misalignments in the form of track buckles on a very hot day. A number of additional factors combined to contribute to each derailment, any one of which may not have resulted in a derailment in its own right.

Considering how unusual it is for two similar derailments to occur approximately an hour apart and within 200 kilometres of each other, extensive examination and analysis of freight loading, train handling, and rollingstock was also conducted.

There was no evidence or indication of any fault, defect or deficiency in freight loading, train handling, or rollingstock that may have directly contributed to one or both derailments or to the development of a track defect subsequently causing one or both derailments.

In the interest of future safety the ATSB has made recommendations regarding management of track stability and movement, procedures for assessing minor defects and identifying factors that may have contributed to the defect, and documenting of procedures for managing safe operations during periods of high ambient temperature.

Read the report: Derailment of Pacific National 6MP4 and Pacific National 6SP5 Trains

An ATSB investigation has found that nobody was assigned to guide the leading end of a shunting movement of a Pacific National freight train which collided with the side of the Sydney to Melbourne XPT on the evening of 19 January 2005 at South Dynon. The ATSB investigation found that factors including the lack of procedures, poor communications, erroneous assumptions and a depleted team of terminal operators all contributed to the collision. The investigation also found that the catchpoints were ineffective in deflecting the wagons away from the main line.

The final investigation report by the Australian Transport Safety Bureau states that three employees were directly involved in the shunting operation, a qualified terminal operator, a trainee and a locomotive driver. The terminal operator stayed with the locomotive to disconnect it from the wagons and allow the front portion of the train to connect. He incorrectly thought that the trainee understood that he was to guide the leading wagon and stop the train short of a signal guarding the main line.

However, the trainee however thought he had to go to a position only halfway down the yard, remove a derailing device (a 'scotch-block') from the rail and wait there until the locomotive reached him, when he would disconnect the locomotive from the wagons. He had done this job on previous shunting movements and he was not qualified to guide the leading wagon.

The locomotive driver was not aware of the exact position of the leading wagon and was receiving 'distance-to-go' information over the radio from the trainee. He continued pushing the wagons until he saw the trainee and then realised that nobody was at the leading end of the shunt and that the distances given by the trainee related to the distance that the locomotive had to go to his position. The driver immediately brought the shunt to a stop. In the meantime the leading two wagons had derailed on catchpoints guarding the main line and continued at a speed of about 9 km/h into the side of the XPT train passing at the time at a speed of about 13 km/h.

Nobody was hurt and relatively light damage was sustained by the XPT.

The ATSB issued two safety recommendations in the course of the investigation and is releasing a further seven recommendations today with the final report.

The ATSB has found that deficient boat design and construction, inadequate equipment and training, fatigue and poor decision-making, weather conditions and regulatory confusion, all combined in the tragic loss of five Torres Strait Islanders travelling on board the 6 metre boat Malu Sara in Torres Strait on 15 October 2005.

According to the final investigation report by the Australian Transport Safety Bureau (ATSB), the boat did not meet basic freeboard or stability requirements. When operating at slow speed or stopped, water flooded the boat's cockpit from the stern freeing port. The four remaining sister vessels had weather decks that were not watertight which allowed water to leak into the hull.

The skipper carried no chart and the only navigation aid with which he was familiar was a magnetic compass. There is strong circumstantial evidence that the skipper did not fully understand the use of either the outboard motors with their separate lubricating oil systems or the satellite telephone system, not having had proper training in either before embarking on the voyage. This was a tragedy waiting to happen.

Malu Sara was one of six boats built in Cairns and commissioned in late August 2005 for the then Department of Immigration and Multicultural and Indigenous Affairs (DIMIA). The ATSB found that the Commonwealth regulatory regime governing the construction and survey of the vessels did not provide sufficient clarity or unambiguous guidance. This led to some confusion by DIMIA, who did not have, or employ, the expertise necessary to prove the seaworthiness of the vessels or understand the various risks inherent in small boat operations.

On 14 October the Malu Sara, was returning from Saibai Island to its Badu Island base, a passage of about 58 miles, with four adults and one four year old child on board. In the afternoon the skipper became lost in reduced visibility. Over a period of almost eleven hours both the DIMIA duty officer and later the Queensland Police Service mission coordinator using emergency position indicating radio beacon (EPIRB) positions, attempted to guide the boat to safety. At 0215 on 15 October 2005, when Malu Sara was just seven miles from its home island, the skipper reported that the boat was taking water and was sinking.

Despite an extensive search over six days no trace of the boat or four of its five occupants was found. One body was recovered by Indonesian fishermen about 50 miles west of Malu Sara's last known position. While there is no certainty as to what happened on the passage from Saibai Island, according to the ATSB, the probability is that fatigue and disorientation in the reduced visibility led to poor decision-making. Satellite telephone position records show that from about 1930 on 14 October Malu Sara remained within 18 km of either Mabuiag or Badu Islands and spent prolonged periods in static positions, probably at anchor.

The parties concerned have implemented wide ranging safety actions to prevent any similar tragedy in the future which are documented in the ATSB report. The ATSB has also made two additional safety recommendations.

An Australian Transport Safety Bureau (ATSB) investigation report, released today, has found that work procedures in the Regency Park rail yard allowed a shunter to ride on the end-steps of a wagon while being shunted and did not require that the driver confirm that the shunter was safe and/or in a safe position before starting a shunt movement.

The dangers involved in railway shunting accidents were tragically illustrated when a railway employee was severely injured and disabled after a string of wagons ran over him. The ATSB report of the accident on 2 February 2005, cites poor work practices and weak communications protocols between the driver and the shunter that resulted in permanent and severe injuries to the shunter.

The ATSB report states that the accident occurred whilst the locomotive was pushing nine wagons. Near the conclusion of the movement, the driver of the locomotive radioed the shunter to establish his whereabouts. When the shunter failed to reply, the driver stopped the train and left the cab to look for the shunter. As the driver left the cab he saw the shunter lying face down between the tracks.

The ATSB concluded that given the location in which the shunter was found, the design of the wagon and related site evidence, that either:

• the shunter fell from the end step of the leading wagon; or
• the shunter was run over by the wagon just before, or as, he attempted to board the wagon's end step.

While the report concludes that safety actions implemented immediately following the accident are likely to have prevented a similar accident, the investigation identified further opportunities to improve railway operational safety and made eight safety recommendations.

An Australian Transport Safety Bureau study covering 16 years, from 1990 to 2005, has shown a fall in the number of fatal commercial aviation accidents in Australia.

The ATSB report Analysis of Fatality Trends involving Civil Aviation Aircraft in Australian Airspace between 1990 and 2005 was released today.

Using the broadest definition of commercial aviation to include both regular public transport (RPT) and general aviation except for business/private and sport aviation, the report shows a significant decrease in the number of fatal accidents between 1990 and 2005.

There was an increase in fatal accidents and fatalities for commercial operations during 2005, compared with 2004, which was the lowest recorded for the period examined for each measure.

Even using the broadest definition of professional pilot, the data show no significant trend in fatalities involving professional pilots from 1990 to 2005 but a significant decline in the fatal accident trend.

Fatal accidents and fatalities involving professional pilots were much higher compared with private pilots in 1993, 1994 and 2000 than in 2003, 2004 and 2005. The gap (related to hours flown) is neither recent nor growing, the report concludes.

Between 1990 and 2004 (the last year for which activity data is available) commercial aviation operations recorded an average of 0.6 fatal accidents per 100,000 hours flown compared with an average of 2.4 fatal accidents per 100,000 hours flown for non-commercial operations.

There were four low-capacity RPT fatal accidents involving 32 fatalities recorded in the ATSB database from 1990 to 2005 including a 1995 training accident in which there were no passengers on board. The other three low-capacity RPT accidents were Monarch (1993), Whyalla (2000) and the recent (2005) accident at Lockhart River.

The ATSB found that the total number of fatal accidents and fatalities declined significantly in the period from 1990 to 2005. The largest number of fatal accidents (30) and fatalities (64) was recorded in 1990. The lowest number of fatal accidents (10 and 11) and fatalities (24 and 23) occurred in 2002 and 2004. In 2005 there was an increase in the number of fatal accidents and fatalities to 13 and 34 respectively compared with 2004. But the number of fatal accidents and fatalities reported in 2005 was below the annual average (20 and 40 respectively) for the 16-year period.

While any aviation fatality is a tragedy and must never be complacent, the ATSB's analysis shows that the fatal accident rate for both commercial and non-commercial operations is very low and has declined significantly between 1990 and 2005.

The report notes that Australia still has the best international record in high-capacity regular public transport (RPT) with no hull losses or fatal accidents involving passenger jet aircraft.

ATSB data and analysis released today refutes recent claims reported in the media that the commercial aviation fatal accident rate in Australia is increasing and that the number of aviation fatalities involving professional pilots in Australia over the last three years is very high compared with the years since 1990.

Australia still has the best international record in high-capacity regular public transport (RPT) with no hull losses or fatal accidents involving passenger jet aircraft.

Even using the broadest definition of commercial aviation to include both RPT and General Aviation except for business/private and sport aviation, shows a significant decrease in the number of fatal accidents between 1990 and 2005 (Fig 1). Although there was an increase in fatal accidents and fatalities for commercial operations during 2005, 2004 was the lowest recorded for the period examined for each measure.

Using the broadest definition of professional pilot, the data show no significant trend in fatalities involving professional pilots from 1990 to 2005 but a significant decline in the fatal accident trend (Fig 2). Fatal accidents and fatalities involving professional pilots were much higher compared with private pilots in 1993, 1994 and 2000 than in 2003, 2004 and 2005. The gap (related to hours flown) is neither recent nor growing.

Between 1990 and 2004 (the last year for which activity data is available) commercial aviation operations recorded an average of 0.6 fatal accidents per 100,000 hours flown compared with an average of 2.4 fatal accidents per 100,000 hours flown for non-commercial operations.

There were four low capacity RPT fatal accidents involving 32 fatalities recorded in the ATSB database from 1990 to 2005 including a 1995 training accident in which there were no passengers on board. The other three low capacity RPT accidents were Monarch (1993), Whyalla (2000) and the recent accident at Lockhart River.

The ATSB found that the total number of fatal accidents and fatalities declined significantly in the period from 1990 to 2005. The largest number of fatal accidents (30) and fatalities (64) was recorded in 1990. The lowest number of fatal accidents (10 and 11) and fatalities (24 and 23) occurred in 2002 and 2004. In 2005 there was an increase in the number of fatal accidents and fatalities to 13 and 34 respectively compared with 2004. But the number of fatal accidents and fatalities reported in 2005 was below the annual average (20 and 40 respectively) for the 16-year period.

While any aviation fatality is a tragedy and we must never be complacent, the ATSB's analysis show that the fatal accident rate for both commercial and non-commercial operations is very low and has declined significantly from 1990 to 2005.