The ATSB's final investigation report into an aircraft accident near Willowbank in Queensland last year, resulting in five deceased persons and two seriously injured survivors, found that the aircraft's performance prior to impacting a large tree and crashing into a dam was consistent with an engine power loss.

The Australian Transport Safety Bureau report states that technical examination of the Cessna 206's engine and its associated components did not reveal anomalies with the potential to have individually contributed to the partial engine power loss and loss of climb performance about 100 feet above ground level.

The investigation could not discount the potential that a number of less significant anomalies that were identified, may have coincided on 2 January 2006 to reduce the available engine power.

Laboratory examination of the fuel used in the aircraft was found to be outside specification. However, fuel quality experts that were consulted during the investigation indicated that there was minimal potential for the quality of the fuel to have negatively affected the engine's performance.

The investigation determined that the aircraft was being operated in an overweight condition, but because of limitations in the available performance information on the highly-modified aircraft, the effect of that overloading could not be quantified.

The report outlines safety action taken by the Australian Parachute Federation (APF) and contains seven safety recommendations to the APF, the Civil Aviation Safety Authority and the US Federal Aviation Administration to enhance future safety.

As a result of this and a number of other accidents involving partial engine power loss, the ATSB has initiated a special investigation into the factors that affect loss of control following engine power loss (including partial power loss) after takeoff.

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

The first ATSB graduates from the recently accredited Diploma of Transport Safety Investigation were presented with their awards on 18 October 2002.

Senior ATSB investigators Alan Stray, Kit Filor and Kerryn Macaulay received their Diplomas after successfully completing the streamlined assessment process aimed at recognising prior learning and current competency.

Awards were also made to 12 staff who successfully completed a Certificate Level 4 course in Assessment and Workplace Training. This qualifies them to train and assess at the Diploma level.

The awards are the first since the Bureau received its recent national accreditation for the Diploma program and accreditation as a Registered Training Organisation (RTO).

In presenting the awards Kym Bills, Executive Director of the Bureau, noted that the transport safety investigation course is believed to be the first of its type in the world. There has been domestic and international interest in the course already expressed from industry, transport regulatory authorities and other government bodies.

Mr Bills noted that this is an excellent achievement for the Bureau and re-inforces the world-wide standing of ATSBs safety investigation capability.

The Diploma course is aimed at providing basic investigation training to investigators in air, marine and rail transport modes. The course offers a structured learning framework through a combination of formal course work, self-paced learning guides and on-the-job training to provide trainees with the essential knowledge, skills, experience and competencies.

Duration of the course will vary according to current competency and prior learning, but new recruits could complete the course in 18 months as an integral part of their work in the Bureau. The course also links to investigator Work Level Standards.

The Diploma program will cover a range of generic and technical competencies relevant to transport safety investigation. These include technical report writing, data collection and analysis, and the final competency of managing a (less complex) transport safety investigation.

Development of the course commenced in 2000 when the Bureau identified the need for a vocational educational and training qualification to address the requirements of Transport Safety Investigators. The Bureau realised that a structured learning program would be necessary to develop the skills of new recruits before more experienced investigators leave the organisation. In addition, the Diploma could also prove useful in the context of the increasingly litigious environment in which the Bureau operates.

With the focus of the Bureau on no-blame safety investigations, it was not possible to simply adopt existing investigation courses aimed at apportioning fault or blame. The Bureau, with assistance from the Canberra Institute of Technology (CIT) Solutions, developed its own enterprise-specific standards consistent with its no-blame safety investigation philosophy and the Bureaus international obligations and legislation.

In addition to offering a Diploma for successful completion of the full course, the Bureau may now also offer Certificates to successful external candidates of short courses conducted by the Bureau such as the well-known course on Human Factors for Investigators.

Administration of the RTO will be in accordance with the national standards issued by the Australian Quality Training Framework. All aspects of the course will be continually monitored and evaluated to ensure the training remains effective and relevant to the needs of the Bureau.

Opportunities may exist for commercial development of the course. However, the immediate ATSB priority is to ensure ATSB staff obtain the full benefit from what the course has to offer to maintain Australias position at the forefront of transport safety investigation.

The Australian Transport Safety Bureau has released its final report after an almost two-year investigation of the systemic factors behind the groundings of Ansett B767 aircraft.

While Ansett has ceased flying, the ATSB continued its investigation because of the importance of the issues involved for the safety of 'Class A' aircraft around the world.

The ATSB found that in addition to errors and omissions by individuals in Ansett, there were deeper system and resource weaknesses in the airline group and shortcomings by the US regulator of the aircraft type (the FAA) both of which CASA was unaware.

The Boeing 767 aircraft was among the first in the world to be designed and certified under damage tolerance principles. This meant that while some aircraft structural fatigue cracking was expected, a robust system for regular inspection and maintenance was essential to assure continuing airworthiness.

Ansett omitted to action 25,000 flight cycle inspections issued by Boeing in June 1997 and updated in June 2000 to include fatigue crack inspections of the aircraft tail. It also failed to action within the recommended six months a March 2000 Boeing 'Alert' service bulletin relating to possible cracking in B767 engine mount fittings.

The FAA did not mandate Boeing's June 1997 inspections and subsequent service bulletins until after the second Ansett groundings in April 2001. Boeing did not highlight the potential safety significance of the tail cracking issue in its service bulletin until November 2001 - prior to this Boeing's focus was on it being a commercial issue.

The former CAA had reduced the Australian regulator's in-house capacity to review important safety service bulletins and relied on foreign regulators like the FAA and operators like Ansett to do so. CASA was unaware of delays in the FAA and did not appreciate the extent of problems involving Ansett's maintenance. Vulnerability was compounded by weaker than desirable feedback systems for maintenance issues.

The action by Ansett and CASA to ground the B767 aircraft until safety could be assured protected the flying public. The ATSB issued two recommendations in April 2001. CASA also conducted an extensive review and is addressing its findings.

The ATSB is today making a further 11 recommendations to ICAO, the FAA, and CASA designed to augment the safety defences for Class A aircraft such as the B767.

The Ansett 767 maintenance case highlights the need for organisations to be continually mindful of potential threats to aviation safety, particularly when commercial pressures intensify and there are significant changes to structures and the broader environment.

Failure to keep a proper lookout, a faulty radio and fatigue resulted in a collision between two vessels off the coast of Western Australian on 18 January 2001, according to an investigation report released by the Australian Transport Safety Bureau today.

The report states that the collision occurred at 0435 local time, 14 miles off the coast when the rock lobster fishing vessel, Lipari, struck the side of the Hong Kong flag bulk carrier, Handymariner. The ship sustained no damage in the incident but the fishing vessel was holed on the starboard bow above the waterline. There were no injuries sustained by the crew of either vessel.

Lipari had left Port Bouvard, south of Fremantle, earlier on the morning of the incident to check lobster pots set some 36 miles offshore. Shortly after leaving port, the vessel's two deckhands had gone below to sleep while the skipper stayed in the wheelhouse with the vessel's autopilot engaged.

The mate on watch on the south-bound Handymariner had detected Lipari on radar some 25 minutes before the collision. He had attempted to call the fishing vessel on marine radio but Lipari's radio was not working and so his calls went unheard. The mate then attempted to warn the fishing boat using a signal lamp and the ship's whistle but still received no response. Lipari had maintained a steady course and speed towards the ship. When the collision was imminent, the mate had altered the ship's course to starboard.

Just before the two vessels collided, the skipper in Lipari's wheelhouse had heard the ship's whistle. He realised at that point that there was a ship dead ahead and so turned the fishing vessel's helm hard to port to try to avoid the collision.

The report concludes that the look-out maintained on Lipari was inadequate, with the lack of an operational VHF marine radio on the vessel also contributing to the incident. The investigation also revealed that it was probable that Lipari's skipper was suffering from some affects of chronic fatigue which may have led to his poor situational awareness and poor look-out in the time leading up to the collision.

The report recommends that all commercial vessels operating offshore be required to carry operational VHF radio equipment and that State and Territory marine authorities review work practices and manning levels on fishing vessels to establish guidelines for the management of crew fatigue.

Air Safety Investigation Report 200100348 Fact Sheet

On 18 November 2001, a ballast tank of the Hong Kong-registered bulk carrier Nego Kim exploded killing eight crew members.

The Australian Transport Safety Bureau (ATSB) investigation has found that the explosion occurred when volatile paint fumes inside the inadequately ventilated tank were ignited.

The ATSB released the results of its investigation today.

The report states:

• The explosion occurred at 4.40pm on Sunday 18 November 2001, when the ship was anchored inside Dampier port limits waiting to load a cargo of scrap metal.
• Prior to the explosion, eight crew members had spent two hours spray painting inside a topside ballast tank.
• The explosion occurred when volatile paint fumes inside the inadequately ventilated tank were ignited, probably by the electric lead light the men were using.
• Three of the crew were killed when the tank ruptured. Four other members of the crew were blown over the side of the ship. The search and rescue operation mounted by local authorities recovered one body 23 hours later.
• The eighth crew member, who was probably working inside the tank, survived the explosion but died of his injuries in Royal Perth Hospital 16 days later.

The ATSB identified that the crew were not provided with adequate instructions or equipment for the painting work and were unaware of the dangers associated with the task.

The investigation also found that Dampier Port Authority's emergency response plan was deficient as it did not reflect the changed role of the authority in an emergency, following the closure of the port communications tower some months earlier.

As a result of the investigation, the ATSB has issued three recommendations:

• International Safety Management (ISM) manuals should include clear instructions for all operations in enclosed spaces, including the hazards of any operation and instructions regarding the wearing of appropriate clothing and protective equipment.
• ISM manuals should provide guidance on the conditions under which work in enclosed spaces should be undertaken.
• The Port of Dampier draft Emergency Response Plan should be reviewed to remove ambiguities and to ensure a consistent and appropriate approach to emergency situations within the port, including clear communications.

The report Marine Safety Investigation Report 174, is available from the website.

The ATSB today released its interim report on the fatal accident involving a Piper PA-28-161 aircraft and a Socata TB-9 aircraft near Bankstown Aerodrome on 5 May 2002.

Four people died in the accident, which occurred when the Piper (call sign VH-IBK) and Socata aircraft (call sign VH-JTV) collided about 2km ESE of the aerodrome, while on final approach to the runway.

The Piper aircraft had departed Wagga Wagga at about 1.34pm that day on a private flight to Bankstown, with a private licensed pilot and three passengers on board.

The Socata aircraft, with a flight instructor and student pilot on board, was conducting circuit training at Bankstown Aerodrome on runway 29L via left circuits.

The interim report states:

• The Socata pilots reported that, after they completed the turn onto final approach, their aircraft was lined up for runway 29L.
• Soon after, the instructor pilot saw the Piper was positioned close to the right of their aircraft and on a rapid collision course with the Socata.
• The two aircraft collided at about 3.25pm.
• Following the collision, the instructor pilot landed the Socata safely and the two pilots were uninjured.
• All on board the Piper died in the accident.

The ATSB investigates accidents in order to identify the contributing factors and to make safety recommendations which may prevent such accidents from happening again. The ATSB does not investigate for the purposes of apportioning blame or liability.

The interim report is a summary of factual information known at this point in time.

The report Interim Factual Report 200201846, is available from the website.

At approximately 1745 hrs on 26 September 2002, a single-engine Piper Cherokee Six aircraft, with 6 people on board crashed and caught fire shortly after take-off from Hamilton Island. All occupants were fatally injured.

A team of Transport Safety Investigators from the Australian Transport Safety Bureau (ATSB) is expected to arrive at the scene of the accident sometime during the afternoon today to commence an investigation into the circumstances surrounding this tragedy.

The investigator-in-charge (IIC) of this accident is expected to give a media briefing from the accident site at 1500 hrs today. However, please contact the ATSB on 1800 020 616 for confirmation of the briefing time.

The ATSB investigators will be examining the wreckage and aircraft documentation and would like to talk to any witnesses to this accident. Witnesses are asked to contact the ATSB on 1800 020 616.

In accordance with its policies and procedures, the ATSB is expected to issue a preliminary report concerning this accident in approximately 30 days.

ATSB releases preliminary report on Hamilton Island crash

Container ship's contact with a navigational beacon in Moreton Bay.