A study by the ATSB has shown that just under half of the general aviation fatal accidents in the ten year period between 1991 and 2000 were Uncontrolled Flight Into Terrain (UFIT) accidents, where an intact aircraft collided with a stationary obstacle or terrain after an in-flight loss of control had occurred.

In more than half of the UFIT fatal accidents an event that was either not averted, or not managed appropriately by the pilot, or was not within the pilot's control, preceded the loss of control. However, in the vast majority of UFIT fatal accidents that occurred during low-level flying operations, there was no precipitating event and the loss of control situation could not be corrected before the impact, given the aircraft's height above the ground when the loss of control occurred.

Controlled Flight Into Terrain (CFIT) fatal accidents (where an aircraft collided with a stationary obstacle or terrain during powered, controlled flight, taking the pilot unawares) was the second most common accident type (30 per cent of fatal accidents).

The majority of CFIT fatal accidents occurred during low-level flying operations, when the visibility was adequate: most of these accidents were wirestrikes. Pilots involved in fatal CFIT accidents who were flying unnecessarily low accounted for a quarter of all CFITs. They also accounted for 42 percent of all CFITs during low-level flying operations. The large majority of CFIT fatal accidents that happened when the pilot did not plan to conduct low flying operations, occurred when the pilot was not able to see the outside environment. This happened under visual flight rules or instrument flight rules, and was due to either poor visibility or darkness.

Research also showed that general aviation occurrences between 1700 and 2059 were 1.6 times more likely to be fatal than during other times of the day. Furthermore, occurrences involving private/business operations were 1.9 times more likely to be fatal over the weekend than during the working week.

Depending on the scale of feedback about this report, the ATSB will consider releasing a supplementary section of this report that addresses issues and questions that have been raised.

The ATSB has released a major accident report on behalf of the Government of East Timor into the fatal accident on 31 January 2003 which resulted in six fatalities.

The ATSB found that the accident occurred when a large Russian-made Ilyushin IL-76 cargo jet aircraft crashed at Baucau, East Timor in bad weather after impacting terrain while attempting to land.

On behalf of the East Timor Government the ATSB, with the assistance of Australian Defence (DFS-ADF and DSTO) officers and the Moscow-based Commonwealth of Independent States Interstate Aviation Committee, investigated the accident.

The final investigation report was released following a briefing provided late yesterday by the ATSB and the Australian Ambassador to the Prime Minister and other members of the Timor-Leste Ministerial Council.

While it is not the object of an ATSB investigation to apportion blame or liability, the investigation found in addition to the bad weather, the aircraft crew didn't have accurate aerodrome charts and there was poor crew resource management (CRM) in the cockpit.

The aircraft descended below the lowest safe altitude for the sector and impacted terrain well short of the runway in a controlled flight into terrain (CFIT) accident which is a preventable but common cause of major accidents around the world.

Safety recommendations from the report to avoid CFIT include better use of available technology and equipment, implementing standard operating procedures, and improving collegiate crew decision-making, risk assessment and management.

The ATSB's aviation safety survey of commercial pilots, Common Flying Errors, has revealed that, violations of standard operating procedures were more prevalent in general aviation and were involved in 11.8% of all events.

The survey asked pilots to identify the main factors contributing to errors and the defences they used to recover. Most errors occurred en route, distantly followed by flight preparation errors.

All categories of pilot experienced errors while executing procedures en route, such as not completing their landing checklist, and misprocessing information from their operational environment, such as an unexpected decline in weather conditions. Most identified errors involving mishandling as a concern, such as heavy landing; misconfiguration, such as landing with the flap setting one less than configured for; and misprocessing navigational information, such as an incorrect GPS identifier.

The contributing factor identified by all categories of pilot as enhancing the likelihood of error was lack of pilot experience. Failing to complete procedures, such as not cross-checking figures, and experiencing problems with systems equipment, such as frequency congestion, also exacerbated errors in most categories.

Operational personnel across all flight categories indicated that there was frequently no defence present to protect against the error. When a defence was available, pilot skills and implementing procedures predominantly enhanced error recovery. Very few pilot responses indicated that a defence had been employed after the event to reduce the potential of recurrence.

Overall:

• violation of standard operating procedures was involved in 11.8% of events;
• wilfully risky activities were present in 3.2% of error events;
• in 2.1% of reported events an accident occurred;
• 9.1% of respondents were involved in a concern relating to a mid-air collision, most of which involved no warning (unalerted confliction 6.1%).

Some caution is required when interpreting results because considerable amounts of data were missing. The survey conveys the opinion of pilots and not the opinion of the ATSB. Results do not suggest that aviation is more at risk of error than other transport activities.

After allowing for activity levels, ATSB research indicates that Robinson R22 helicopters have a similar safety profile to other comparable helicopters.

This study was prompted by increasing concerns about light utility helicopter safety in Australia. Light utility helicopters make up half the registered fleet yet were involved in 72 per cent of all helicopter accidents between 1985 and 2003.

The report compared accident involvement and accident rates of four helicopter models; Robinson R22, Bell/Agusta/Kawasaki 47G, Hughes/Schweizer 269 and Hiller UH-12E.

The Robinson R22 was involved in more accidents and fatal accidents than any other light utility helicopter but also flew more hours than the other three helicopters whose risk profiles were studied. The Bell/Agusta/Kawasaki 47G model had the next highest involvement in accidents followed by the Hughes/Schweizer 269 and then the Hiller UH-12E. However, when comparing the relative safety of different aircraft models the best available indicator is the accident rate per hours flown.

The overall trend in accident involvement and accident rate per hours flown has improved since 1990 for all the light utility helicopter models. The accident rate per hours flown for the Robinson R22 model indicates that up to 2002 this helicopter's record was as safe, if not safer, than other similar helicopter models. Since 2002, the Bell/Agusta/Kawasaki 47G model has had the lowest accident rate per hours flown.

For the combined period, 1990-2002, the Robinson R22 had the lowest accident rate per hours flown of 1.8 accidents per 10,000 flying hours compared with the next lowest rate for the Bell/Agusta/Kawasaki 47G of 3.1 accidents per 10,000 flying hours.

As of 20 May 2004, seafarers will be able to make their safety concerns known under a new AUSTRALIAN GOVERNMENT safety initiative.

The Australian Transport Safety Bureau (ATSB) is introducing a Confidential Marine Reporting Scheme (CMRS) to improve safety in Australian waters by preventing or reducing the risks of marine accidents.

The marine industry, which was widely consulted on the scheme, has welcomed its introduction.

Seafarers and others connected with the marine industry will now be able to report, confidentially, any unsafe conditions, practices or procedures on ships. The scheme is also intended for use, for instance, by a passenger on a ship or a person ashore who observes and wishes to report a marine safety issue.

Under the Transport Safety Investigation Act 2003, the ATSB investigates and reports on marine accidents. Now, under the Navigation (Confidential Marine Reporting Scheme) Regulations 2004, the ATSB will accept and act, where appropriate, on confidential marine reports.

All reports will be processed to ensure that the identities of reporters are kept confidential.

The scheme encourages the reporting of safety issues by ship's crews and people concerned for maritime safety. However, it may not be used by masters and others who have an obligation, under other legislation, to report accidents where they were involved. Neither is the scheme intended for reporting industrial relations issues or unlawful interference with a ship.

Reports will be accepted by phone, email, fax or on-line or by using the ATSB's confidential marine reporting form. Any reference to, or any information that might identify, a reporter will be removed to 'de-identify' each report. Reports will then be assessed by experienced mariners who will determine what action is required. The de-identified information will be entered into a secure database to enable the reports to be analysed for safety information or trends.

The information from confidential reports may be forwarded by the ATSB to the Australian Maritime Safety Authority. The information may also be used to issue information briefs or alert bulletins to the maritime community. The ATSB will publish reviews of information from confidential reports and will assess the effectiveness of the scheme with a committee established for that purpose.

A new ATSB research investigation report analyses the 37 midair collisions in Australia from 1961 to 2003. None involved scheduled passenger (RPT) aircraft and over three quarters involved general aviation aircraft that collided in good weather in or near the circuit area of an airport.

Of the 78% of midair collisions in circuit areas, nearly half occurred on the final leg of the circuit or on the base-to-final turn. Most midair collisions occurred between aircraft converging on similar courses, or flying in the same direction. A range of contributing factors were evident, but there were no dominant factors.

Nineteen of the collisions resulted in fatalities. A high proportion of the midair collisions occurred at the five major Australian general aviation airports; namely Archerfield, Bankstown, Jandakot, Moorabbin and Parafield.

The rate of midair collisions between 1981 and 2003 was similar to the rate in the US, however the US had a higher proportion of midair collisions away from the circuit area. This is consistent with the greater traffic density and general aviation flying activity in the US.

The characteristics of the contributing factors involved in Australian midair collisions were generally similar to those observed in other countries, such as the US, France and Canada.

The ATSB is seeking comment on its Aviation Research Discussion Paper by 31 May 2004, with a view to incorporating supported suggestions for improvement.

An ATSB interim factual investigation report has found that the airspace incident near Brisbane on 7 April involving a B737 and a Lancair aircraft was not an 'airprox' event.

In this incident, the two aircraft passed with 600 feet vertical and 0.4NM (about 1 km) lateral separation in new Class E airspace, but were not in danger of collision.

Unlike the Launceston airprox last Christmas Eve, in this incident the smaller Lancair aircraft was on air traffic control radar and in communication with controllers and the B737 aircraft had initiated a change of flightpath before receiving two TCAS alerts.

The Lancair pilot informed the controller that he had the B737 in sight. While the B737 crew were unable to see the Lancair, they noted its presence on TCAS prior to the TCAS traffic advisory (TA) and resolution advisory (RA) alerts and they also received three reports of traffic from the air traffic controller.

The ATSB's interim factual report states that the Boeing 737-7BX, operating under the instrument flight rules (IFR), was en route from Townsville and descending for a landing at Brisbane, while the Neico Lancair IV-P, operating under visual flight rules (VFR), was en route from Maroochydore to St George, on climb to flight level (FL)165.

As the B737 was approaching FL 157, the crew noted the Lancair via the aircraft traffic alert and collision avoidance system (TCAS). At that point the crew reduced the rate of descent. Thirty seconds later they received a TCAS TA. Recorded data from the B737's flight data recorder indicated that the crew levelled the B737 at FL 153, and then climbed to FL 154 and commenced a right turn away from the Lancair.

About 22 seconds later, the crew received a TCAS RA instructing them to climb. They subsequently climbed the B737 to FL 166 and continued the right turn to about 15 degrees right of track. Recorded radar data indicated that the Lancair passed behind and below the B737. The minimum distance between the two aircraft was about 600 feet vertically and 0.4 NM laterally.

Information obtained from the crews of both aircraft, the Airservices ATS controller, recorded flight data from the B737, ATS audio recordings and radar data, is consistent and indicates that the crews of both aircraft and the ATS controller complied with the published procedures for Class E airspace under NAS 2b.

The ATSB has found that the Bankstown midair collision accident was the result of a Piper Warrior passing through the extended centreline of runway 29 centre, to which the pilot had been cleared, and continuing on to the extended centreline of runway 29 left.

The Piper collided with a Socata Taralga, which had been cleared for its final approach to the left runway. The Piper became uncontrollable and crashed in an industrial area to the south-east of the airport. All four occupants were fatally injured. The Socata landed at Bankstown and its occupants were uninjured.

General Aviation Airport Procedures (GAAP) were in operation at the time of the accident. Under GAAP, pilots operating in visual meteorological conditions were responsible for aircraft separation when airborne in the circuit. Air traffic controllers were responsible for issuing sequencing instructions and providing traffic information to assist pilots to avoid other traffic. The pilot of the Piper was issued traffic information on the Socata and the pilots of the Socata reported that they saw the Piper.

A number of aircraft were conducting training circuits on runway 29 left (via left circuits) and other aircraft were arriving and departing Bankstown on runway 29 right (via right circuits). The pilot of the Piper had requested, and been issued with, a clearance to land on runway 29 centre from a right circuit and the pilots of the Socata had been issued with a clearance to conduct a touch and go landing on runway 29 left from a left circuit.

A significant proportion of GAAP operations at Bankstown involved contra-circuits onto runways 29 left and 29 centre, which were 107 m apart. Contra-circuit operations to runways less than 213 m apart were permitted, provided that the air traffic controllers provided traffic information to pilots about aircraft in the opposite circuit.

The investigation concluded that there were insufficient visual cues for a pilot in one circuit to reliably assess the collision potential of an aircraft in the opposing circuit, when both aircraft were conducting contra-circuits to parallel runways 107 m apart.

In December 2003, Airservices Australia, modified its procedures for Bankstown so that, where aircraft involved in contra-circuits are likely to be at base or final legs at approximately the same time, the use of the centre runway would be denied.

The ATSB has issued recommendations to Airservices Australia and CASA regarding the estimation of overall midair collision risk at major GA airports, and the provision of advisory material for pilots about collision risk management strategies.

ATSB analysis indicates no adverse safety trend since NAS stage 2b was introduced on 27 November 2003 based on the ATSB's preliminary review of its aviation safety occurrence database, including an examination of TCAS resolution advisory alerts.

Because of the significance of NAS airspace changes and public debate over the safety of their implementation, the ATSB has reviewed and categorised NAS-related occurrences and undertaken a comparative analysis of TCAS resolution advisory (RA) alerts in the 140 days from 27 November 2003 with 140 days a year earlier.

There were 37 RAs after NAS 2b was introduced and 38 RAs in the same period a year earlier - accordingly, no trend is apparent. One of the RAs in each period was indicative of a more serious safety situation. A second RA on 7 April 2004 in the latter period was still under investigation.

The one serious RA occurrence after NAS 2b was introduced occurred at Launceston on 24 December 2003. The ATSB assessed this as an 'airprox' incident and noted that: While a single occurrence does not provide the basis for a major change to the US-based NAS, which is yet to be fully implemented, the circumstances of this serious incident are indicative of a need for further review and analysis by CASA and Airservices Australia in consultation with industry. Such reviews have been initiated.

In the pre-NAS 2b period, the one more serious RA occurrence was associated with a 'breakdown in separation' in Class C airspace linked to an air traffic control oversight. At their closest, the two jet aircraft involved came within 1200 feet vertically and 2.5 NM laterally.

The ATSB is seeking comment on its Aviation Research Discussion Paper by 21 May 2004 with a view to incorporating suggestions for improvement in the context of a proposed publication in July containing six months of post-NAS 2b occurrence data.

Today the ATSB is issuing a preliminary report of the investigation into the accident involving an Aero Commander 500-S, registered VH-LST.

The accident occurred on 19 February 2004, at about 1700 Eastern Summer Time (ESuT), approximately 58km NNW of Hobart Aerodrome.

The report provides factual information as at 29 March 2004.

The aircraft departed Hobart Airport for Devonport, Tasmania at about 1643 ESuT. The pilot made several radio transmissions, the last indicating that the aircraft had left 4,500 ft on climb to a cruising altitude of 8,500 ft.

The wreckage pattern indicates that the aircraft sustained a structural failure resulting in airframe disruption while airborne. The reason for the structural failure is still under investigation.

The investigation is continuing and is examining several aspects in relation to the accident, including the aircraft structure, maintenance, flight operations, air traffic control, meteorological conditions and human performance.