Rail 2007, Sydney NSW, 3 April 2007

The increasing cooperation between Australian transport safety investigators and their counterparts from the Commonwealth of Independent States (CIS), has been recognised by the signing of a Memorandum of Understanding this morning.

The Memorandum was signed by the Australian Transport Safety Bureau (ATSB) and the Interstate Aviation Committee (IAC), representing 12 Independent States: Azerbaidjan, Armenia, Belorus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russian Federation, Tajikistan, Turkmena, Uzbekistan and Ukraine.

This agreement sets out protocols for the sharing of expertise and experience relating to investigations, with the sole objective of improving the safety of air transport, ATSB Executive Director, Mr Kym Bills, said.

We are working closely with the IAC on the investigation into the crash of a Russian aircraft near Cakung Airport, Baucau, East Timor, on January 31 this year.

The IAC represents the country of manufacture and design of the aircraft involved.

IAC investigators are assisting with information about the aircraft as well as flight recorder replay and analysis.

The ATSB and IAC investigate accidents and incidents so that the industry can prevent such occurrences from happening again as enshrined in Annex 13 to the Convention on International Civil Aviation, we do not investigate with a view to blame or liability.

Both Australia and the Commonwealth of Independent States are also members of the International Transport Safety Association (ITSA), the International Society of Air Safety Investigators (ISASI) and the Flight Safety Foundation (FSF).

In the Memorandum, the ATSB and IAC have agreed to:

• Provide assistance, in the form of investigation facilities and equipment, as resources permit. This assistance may include expertise in the fields of air traffic services, engineering, operations, flight recorders, human performance and management organisation.
• Appoint investigators as observers or participants in investigations, with a view to improving understanding of each others investigation requirements and procedures.

The Memorandum applies to:

• Aircraft, operated by the States-signatories, in the territory of Australia; and
• Australian-operated aircraft in the territory of the States-signatories.

Mr Bills said the Memorandum would serve to build the ATSBs experience and offer valuable opportunities to share information and expertise.

Speech given to International Transport Safety Association by Kym Bills Executive Director, Australian Transport Safety Bureau

15 May 2007

Speech delivered to Safeskies 07 Conference in Canberra, ACT on The ATSB perspective on Safety Management Systems in Australia by Mr Kym Bills, Executive Director, Australian Transport Safety Bureau.

On 1 March 2003, the Government of Timor Leste released its Preliminary Report into the fatal aircraft accident near Baucau on 31 January 2003.

At the request of the Government of Timor Leste, the Australian Transport Safety Bureau (ATSB) has today posted this preliminary report on its web site.

The Ilyushin IL-76TD aircraft impacted the ground near Cakung Airport, Baucau, during a landing approach. All six crew on board were fatally injured in the crash.

ATSB Deputy Director, Air Safety, Alan Stray said the investigation was continuing.

At the request of the Government of Timor Leste, the ATSB appointed an Accredited Representative to the investigation, who is assisted by investigators from the ATSB, the Directorate of Flying Safety Australian Defence Force and the Defence Science and Technology Organisation, he said.

The investigators are working to identify what factors led to this accident and loss of life and what can be done to prevent it from happening again.

During the preliminary phase of the investigation, we have identified several recommendations for safety actions the Government of Timor-Leste and the United Nations could take to improve flight safety.

The recommendations to the Government of Timor Leste include:

• The development of instrument approach and aerodrome charts for Baucau, Timor Leste;
• That the government review the provision of air traffic services and facilities to aircraft operations into Baucau.

We have also recommended that United Nations Air Operations assist the Government of Timor Leste to develop and promulgate approved instrument approach and aerodrome charts for Baucau, Mr Stray said.

The ATSB has found that the tanker, Dampier Spirit, did not have sufficient speed to safely evade a cyclone that was approaching the coast of Western Australia after its mooring hawser failed on 6 April 2006.

Dampier Spirit is a floating storage and offloading tanker for the Stag oil platform near Dampier, Western Australia, that is usually attached to a mooring buoy one nautical mile from the platform. At the time of the incident, the 106 668 tonne tanker had a partial load of about 12 100 tonnes of crude oil on board.

At 0958 on 6 April 2006, the ship was forced to put to sea as Cyclone Hubert approached when the mooring hawser attaching the ship to the buoy failed under load. The ship's master had delayed making the decision to disconnect from the buoy when the cyclone was declared, a delay which effectively reduced the time available to navigate the ship safely out of the cyclone's path.

Once disconnected from the buoy, the ship had difficulty making sufficient headway in the strong winds and heavy seas produced by the cyclone because its speed was limited by 'slow steaming' fuel injector nozzles that had been fitted in the main engine and by the build-up of marine growth on the hull.

Dampier Spirit was tracking towards Tryal Rocks for over three hours until the wind eased at 0305 on 7 April, allowing the tanker to sail into safer water. If it had grounded on Tryal Rocks, its cargo of crude oil may have spilled into the sea, resulting in significant damage to the environmentally sensitive mangroves and turtle nesting grounds in the area.

The report also concludes that the company guidelines for disconnection from the CALM buoy did not provide unambiguous advice to the master, the mooring hawser had been weakened by its service conditions and the master did not adequately consider the time needed to safely avoid the cyclone when making the decision to disconnect and depart from the buoy.

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

Copies of the report can be downloaded from the ATSB's internet site at www.atsb.gov.au,

The ATSB has found that a fire on board the Singapore registered ship Java Sea on 24 May 2005 started when hot pressurised thermal oil, possibly in the form of a spray, came into contact with an un-lagged section of the thermal oil heater exhaust piping. The fire was further fuelled by the contents of oil storage tanks located near the seat of the fire.

The Australian Transport Safety Bureau investigation found that the fixed fire extinguishing system was ineffective in extinguishing the fire because the ship's crew could not close the funnel casing ventilation dampers; the diesel generator was not shut down before the system was activated; and the oil tank quick closing valves were not operated.

At about 0540 on 24 May, a fire started in the engine room of the general cargo ship Java Sea while it was berthed in Cairns. Initial attempts by the ship's crew to fight the fire using a fire hose were unsuccessful and the decision was made to operate the engine room Halon 1301 fixed fire extinguishing system.

The release of the Halon 1301 proved ineffective. The fire was eventually extinguished by the Queensland Fire Service, using high expansion foam injected through a hole cut in the base of the funnel at poop deck level, directly above the seat of the fire.

There were no serious injuries as a result of the fire. However, the engine room and accommodation were significantly damaged by the fire and the associated fire fighting activities. The shiphad to be towed to Singapore for permanent repairs.

The report makes recommendations to ship owners, managers and masters with reference to closing arrangements for funnel casing ventilation openings and on board maintenance and emergency procedure manuals.

Copies of the report can be downloaded from the ATSB's internet site at www.atsb.gov.au

A media conference discussing the circumstances of the Bell 206B Jetranger Helicopter that crashed while undertaking water bombing operations during the Canberra Bush Fires of January 2003 will be held at 11.00 am today.

Who: Mr Alan Stray (Deputy Director, Air Safety Investigation)
When: 16 December 2003 (1100 ESuT)
Where: ATSB Headquarters (15 Mort Street, Canberra City)

The report will then be available on the website www.atsb.gov.au.

Note: Media are requested to assemble in the foyer at 15 Mort Street 15 minutes prior to the conference, from where they will be escorted to the conference venue.

The Australian Transport Safety Bureau will be conducting a media interview on the fatal aircraft accident at Bankstown Airport involving a Piper Seneca, VH-CTT.

Who: Ian Brokenshire (Investigator in Charge)
When: 12 November 2003, 1600 ESuT
Where: Near the Aviation Museum on Perimeter Rd, Bankstown Airport. Nearest major intersection is Milperra Rd / Henry Lawson Drive, turn off Henry Lawson Drive into Tower Rd. (Tower Rd leads to Perimeter Rd.)

The ATSB has found that there was no effective lookout being maintained on board either a fishing vessel or a bulk carrier when the two vessels collided off the South Australian coast on 23 April 2007, the latest in more than 50 such collisions investigated.

The Australian Transport Safety Bureau investigation again found that the fishing vessel was possibly difficult to detect, either visually or by radar, because of its timber construction, lack of a radar reflector, paint scheme and the prevailing weather conditions.

On the morning of 23 April, the Australian fishing vessel Peter Crombie was at anchor about 30 miles south of Robe, South Australia and the vessel's three crew members were below decks sleeping. The Panamanian registered bulk carrier Silky Ocean had sailed from Port Kembla, New South Wales, on 21 April, and was en-route to Ardrossan, South Australia.

The weather was fine with a partly cloudy sky and good visibility. There was a swell of about one metre from the east-southeast and seas of about 1.5 m. The wind was from the east-southeast at 12 to 18 knots.

At about 1150, Silky Ocean was on a course of 311(T) when it collided with Peter Crombie. Silky Ocean's bridge watchkeeper had not detected Peter Crombie either visually or on the ship's radar.

After the collision, Peter Crombie's skipper tried to contact the ship using his vessel's VHF radio. However, Silky Ocean's bridge watchkeeper did not acknowledge the call and made no attempt to communicate with the fishing vessel.

While Silky Ocean had sustained no damage as a result of the collision, Peter Crombie's hull had been damaged and the vessel was taking on water. Fortunately, the fishing vessel's bilge pumps were able to keep up with the ingress of water.

Peter Crombie's skipper notified the vessel's owners of the collision and then set a course for Robe. By 1700, the vessel was all fast alongside the wharf in Robe.

The ATSB is concerned that this type of collision continues to occur in Australian waters, sometimes leading to serious injury or fatality; and has issued five safety advisory notices with the aim of preventing similar incidents.

Copies of the report can be downloaded from the ATSB's internet site at www.atsb.gov.au