ATTENTION: Editors/Chief of Staff, Aviation/transport writers

The earlier invitation to attend a MEDIA CONFERENCE

About the Beech Super King Air aircraft which crashed 65km SE of Burketown on 5 September 2000 with eight fatalities, has been amended.

The conference will now be held at 4 PM TODAY, Thursday 7 March.

When: 4 pm. Please arrive in the foyer no later than 3.45pm as we need to escort you to our conference room.
Where: The Australian Transport Safety Bureau at 15 Mort Street Braddon, Canberra.

A hard copy of the report will then be available.

The ATSB's final investigation report into a Piper Chieftain accident near Condobolin, NSW on 2 December 2005, resulting in four deceased persons, confirms that the aircraft broke up during flight when its structural limits were exceeded in the vicinity of thunderstorms.

The Australian Transport Safety Bureau report states that there was no indication, either by way of emergency radio transmission from the pilot, or in a change in the altitude, track and speed of the aircraft as recorded by radar, that the flight was not proceeding normally. Some minutes after the pilot reported diverting left of track to avoid weather, communications with the aircraft were lost.

The absence of an on-board recording device on the aircraft prevented a full analysis of the circumstances of the breakup. However, while post-impact fire damage limited the extent to which some of the aircraft's system's, including the fuel and electrical systems, could be examined, wreckage examination did not reveal any pre-existing fault or condition that could have weakened the aircraft structure and caused it to break up at a load within the design load limit.

A line of severe thunderstorms crossed the aircraft's planned track and were the subject of a SIGMET (significant weather advice) issued by the Bureau of Meteorology. As the SIGMET information did not meet the criteria for direct notification, it was not advised directly to the pilot of the aircraft. The investigation was unable to determine if the pilot had obtained the SIGMET from any of the range of pre and in-flight weather briefing services available to the pilot.

Analysis of the prevailing weather indicated that, immediately before the accident, the aircraft was likely to have been surrounded to the east, west, and south by a large complex of thunderstorms. That situation may have limited the options available to the pilot to avoid any possible hazardous phenomena associated with the storms.

Although, as a result of a review of Flight Information Service initiated in November 2004, Airservices Australia had identified inconsistencies and ambiguities in the provision of Flight Information Service, including Hazard Alert procedures, they were not assessed by the investigation to be contributing factors to the accident. As a result of its review, Airservices Australia initiated changes to the Flight Information Service and Hazard Alerts sections of the Manual of Air Traffic Services and the Aeronautical Information Publication to improve future safety.

While not contributory to the accident, the report identifies a number of inconsistencies between Australian SIGMET issemination procedures and those contained in International Civil Aviation Organization (ICAO) documentation. The report contains recommendations to Airservices Australia and the Civil Aviation Safety Authority to review Australian procedures with a view to minimising those inconsistencies.

The circumstances of the accident are a salient reminder to pilots of their responsibilities to request weather and other formation necessary to make safe and timely operational decisions, and of the importance of avoiding thunderstorms by large margins.

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

The ATSB has found that a lack of communication, hazard awareness and job safety analysis led to a seaman on board the Panamanian registered container ship MSC Sonia being severely burned by steam.

The Australian Transport Safety Bureau investigation also found that the placement of the boiler safety valve vent pipe, and the direction in which it exhausted, meant that any personnel on the funnel casing top platform were vulnerable when a boiler safety valve operated.

At about 0900 on 10 April 2007, a surveyor arrived on board MSC Sonia to carry out a scheduled boiler survey while the ship was alongside Swanson Dock, Melbourne.

The ship's chief engineer and the surveyor went to the engine room and, after visually inspecting the outside of the boiler; they tested the safety cut-out devices. The surveyor then asked for the operation of the safety valves to be tested. The turbo-alternator was shut down to reduce the steam demand and the boiler's two burners were fired manually. The steam pressure started to rise and, at about 0945, when the boiler pressure reached 11 bar, the safety valves operated.

The ship's boatswain and the ordinary seaman had spent all morning on the top platform of the funnel casing painting the main engine exhaust pipes. At about 0945, steam unexpectedly exhausted from the nearby boiler safety valve vent pipe, directly onto the ordinary seaman.

The ordinary seaman was severely burned by the steam. He was assisted down the funnel casing ladder and onto the bridge deck. While he lay on the deck, the crew used a hose to shower him with water to cool his burns.

At 1015, an ambulance team arrived on board the ship and, by about 1100, the ordinary seaman had been landed ashore, placed in the waiting ambulance and taken to hospital.

The ATSB is pleased to report safety action already taken and has issued one safety recommendation and two safety advisory notices with the aim of preventing similar incidents.

The ATSB has found that a fatal collision between The Overland passenger train and tip truck towing a tri-axle trailer occurred because the truck driver probably did not see the train and entered the level crossing after braking too late to stop at the 'Stop' sign.
The Australian Transport Safety Bureau has today released its final report on the investigation of the collision which occurred at the Barpinba-Poorneet Road level crossing, near Wingeel in southern Victoria, on 15 November 2006.

At the time of the accident the crossing was controlled by passive 'Stop' signs and approach warning signs. The investigation established that the truck did not come to a halt at the 'Stop' sign controlling the crossing and concluded that the driver was possibly distracted by the presence of the road-junction ahead. The truck driver was probably unaware of the presence of the train until just before the collision.

The investigation also found that the viewing angle in the direction from which the train approached the crossing was poor. When coupled with the restricted visibility from the truck's cab, it would have been difficult for the truck driver to see the train without coming to a complete stop at the crossing. The investigation also found that when approaching the crossing from the south-west the advance warning signs did not comply with the operative Australian Standard AS 1742.7: Manual of uniform traffic control devices - Railway crossings.

The investigation established that in the circumstances there was nothing that the train crew could have done to prevent the accident.

In the interest of enhancing future road/rail safety the ATSB has made a series of recommendations to address safety issues including the poor viewing angle at the crossing and the non-compliance of the level crossing signage with the relevant standard.

Read the report: Collision between Rigid Tipper Truck/Tri-axle Trailer and The Overland Passenger Train, 4AM8, Wingeel, Victoria, on 15 November 2006

An ATSB report released today shows that the average age of many aircraft in Australia is increasing but that this should not reduce safety if quality maintenance systems are in place.

The Australian Transport Safety Bureau (ATSB) report found that the average age of Australia's turbofan aircraft used in regular passenger transport (RPT) is very low. The fleet of aircraft in the 50,000 kg to 100,000 kg category had an average age of just 6 years by the end of 2005. That was 2 years lower than the average age of this fleet in 1995.

The expansion of Qantas, and the introduction of new aircraft by Jetstar and Virgin Blue has lowered the average age of these aircraft. Aircraft in this category include the Boeing 737 and Airbus A320, typically used in Australian domestic passenger operations, and on some international routes.

The fleet of larger turbofan aircraft (those above 100,000 kg, including the Boeing 747 and the Airbus A330) have an average age of 11 years. This is still relatively low, and consequently, there would be few signs of maintenance problems related to aircraft age in these aircraft.

The ATSB report also examined the age trend for turboprop aircraft, mostly used in low-capacity airline services. Examples of turboprop aircraft operated in Australia include the Raytheon King Air and the Fairchild Metroliner series of aircraft. The turboprop fleet had an average age of 18 years by the end of 2005, which was 2 years older than was the case in 1995. With few new aircraft being manufactured in this category, additional and specific maintenance will be the key strategy to ensure these aircraft meet the necessary airworthiness standards for passenger operations.

The oldest aircraft in Australia are those powered by piston engines. These aircraft, ranging from the small single engine aircraft used at flying schools and in private operations (such as the Cessna 172), to the twin engine aircraft (for example, the Piper Navajo and the Cessna 400 series) used in charter and some low-capacity operations, are on average around 30 years old.

The situation affecting piston-engine aircraft is not a challenge just for Australia. Manufacturing output of these aircraft is only a fraction of the production levels seen in the late 1970s, and some popular twin-engine types ceased production altogether in the mid 1980s.

The ATSB report on aircraft age makes clear that chronological age is not the sole determinant in assessing aircraft age. Flight cycles and maintenance regimes are important factors that influence airworthiness.

Managing the consequences of an ageing aircraft population requires cooperative approaches by operators, manufacturers and national regulators to ensure that any defects identified by one operator are notified quickly and efficiently within the industry. If quality maintenance systems are in place, ageing aircraft need not lead to reduced safety.

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

The ATSB has found that a lack of communication, hazard awareness and job safety analysis led to a seaman on board the Panamanian registered container ship MSC Sonia being severely burned by steam.

The Australian Transport Safety Bureau investigation also found that the placement of the boiler safety valve vent pipe, and the direction in which it exhausted, meant that any personnel on the funnel casing top platform were vulnerable when a boiler safety valve operated.

At about 0900 on 10 April 2007, a surveyor arrived on board MSC Sonia to carry out a scheduled boiler survey while the ship was alongside Swanson Dock, Melbourne.

The ship's chief engineer and the surveyor went to the engine room and, after visually inspecting the outside of the boiler; they tested the safety cut-out devices. The surveyor then asked for the operation of the safety valves to be tested. The turbo-alternator was shut down to reduce the steam demand and the boiler's two burners were fired manually. The steam pressure started to rise and, at about 0945, when the boiler pressure reached 11 bar, the safety valves operated.

The ship's boatswain and the ordinary seaman had spent all morning on the top platform of the funnel casing painting the main engine exhaust pipes. At about 0945, steam unexpectedly exhausted from the nearby boiler safety valve vent pipe, directly onto the ordinary seaman.

The ordinary seaman was severely burned by the steam. He was assisted down the funnel casing ladder and onto the bridge deck. While he lay on the deck, the crew used a hose to shower him with water to cool his burns.

At 1015, an ambulance team arrived on board the ship and, by about 1100, the ordinary seaman had been landed ashore, placed in the waiting ambulance and taken to hospital.

The ATSB is pleased to report safety action already taken and has issued one safety recommendation and two safety advisory notices with the aim of preventing similar incidents.

The ATSB has found that a collision between a train and low loader truck occurred because the truck driver was probably distracted and did not see the train approaching.

The Australian Transport Safety Bureau investigated the collision which occurred at the Magpie Drive level crossing, Tailem Bend, South Australia, on 4 October 2006.

At the time of the accident the crossing was controlled by passive 'Stop' signs and approach warning signs. It is likely that the truck did not come to a halt at the 'Stop' sign controlling the crossing as the driver was possibly distracted by the presence of the road-junction ahead and/or a preoccupation with arriving at his destination on time, which may have diverted his attention from the risks associated with negotiating the level crossing.

The investigation also found that the viewing angle to the north-west of the crossing was substandard and coupled with restricted visibility from the truck driver's cab would have made it difficult for the truck driver to sight the train.

The investigation established that there was nothing the train crew could have done to prevent the accident.

In the interest of enhancing future road/rail safety the ATSB has made a series of recommendations which include opportunities for closure of the level crossing and/or options for improving sighting and viewing angle, enhancing train conspicuity, and expanding the role of the Department for Transport, Energy & Infrastructure Level Crossing Unit's role to include an ongoing level crossing education and audit role.

According to the ATSB investigation, the 'knockdown' of the sail training vessel Windeward Bound, in Bass Strait, was the result of inadequate preparations by the ships crew and the use of excessive rudder movements at the time that a forecast severe cold front passed over the vessel.

On 3 June 2004, Windeward Bound was off the Victorian coast, heading northeast at about six knots. The wind was from the northwest and the vessel was heeled between 10 and 15 degrees to starboard. The upper and lower topsails, the main and fore staysails were set. While a cold front was expected, the ship's master was unaware of the impending gale force winds repeatedly forecast.

At 1726 the helmsman was instructed to run the vessel downwind and shortly thereafter the vessel yawed to port and the helmsman put the rudder hard over to starboard. The watch leader then took the helm and, as the vessel was now swinging to starboard, applied a 'considerable amount' of port rudder. When the vessel had started to swing to port, the rudder was put hard over to starboard to arrest the swing. A gust of near-hurricane force wind then heeled the vessel about 68 degrees to starboard. The vessel was righted after several minutes using the main engine and the rudder and by letting the sheets go.

There was a minor injury to a crew member during the incident and the main engine had been damaged after being run with little or no lubricating oil pressure while the vessel was heeled.
During the next twenty-four hours contact was lost with authorities ashore because of a failure of the ship's generator. An air search was initiated on the afternoon of 4 June and Windeward Bound was found safe and heading for Jervis Bay where it arrived late in the evening of 5 June.

The ATSB investigation found that the ship was not adequately prepared for the passage of the front and that the use of excessive rudder movements caused the vessel to slow sufficiently to broach and then be knocked down.

Significant safety action has already taken place and the ATSB has issued three safety recommendations and one safety advisory notice 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

The ATSB is reviewing scope for possible action against Transair but re-emphasises that this is unrelated to the Transair accident on 7 May 2005 when all 15 on board lost their lives.

The Deputy Prime Minister as Minister for Transport and Regional Services has today been informed that earlier advice from the ATSB suggesting that it was unable to pursue any prosecution with respect to some more serious incidents that Transair failed to report before the accident was incorrect. The ATSB has apologised to the Minister.

The ATSB wishes to highlight that it is an independent safety investigator and not a body that prepares charges after an accident. Its only charge-related role is in relation to breaches of the Transport Safety Investigation Act 2003 (TSI Act), such as through the non-reporting of incidents, and not any charges in relation to the accident itself.

Any prosecution action against Transair and its officers in relation to the fatal accident itself is a separate matter.

As stated in the ATSB's media release of 1 December 2006 and in evidence to the Senate on 15 February 2007 the ATSB uncovered that Transair failed to report 7 immediately reportable matters (IRMs) that occurred between 1 July 2003 and the accident, as well as more routine matters. They include a gear failure on departure from Bamaga, a burning smell near Inverell, and a problem with flaps leading to a flapless takeoff and flight issues from Gunnedah to Sydney. But none of these incidents was linked to the 7 May 2005 fatal accident.

Under the TSI Act such IRMs must be reported immediately by responsible persons (eg Transair) in accordance with the regulations and failure to do so has a maximum penalty of imprisonment for six months (TSI Act Section 18). The Director of Public Prosecutions (DPP) advised the ATSB that under the Crimes Act 1914 a 12-month statute of limitation applied to Section 18 and also with respect to individuals' written reports under Section 19.

However, the DPP also advised that under Section 19 of the TSI Act failure to make a written report of IRMs by a company (ie Lessbrook Pty Ltd trading as Transair) within 72 hours (which carries a maximum penalty of up to 300 penalty units or $33,000) is not time-barred.

The ATSB mistakenly drew the conclusion that all TSI Act prosecution action in relation to IRM incident reports was time barred and will now work with the DPP as a matter of priority to see if a viable prosecution case can be prepared in relation to Section 19.

Separately, the time limits for a prosecution under the TSI Act are being reviewed.

The ATSB has found that the crew on board the Isle of Man registered oil tanker British Mallard did not prevent the ship's elevator car from moving while they were working in the elevator shaft and, as a result, it moved unexpectedly, trapping and killing the ship's electrical technician.

The Australian Transport Safety Bureau investigation found that the ship's crew were either not aware of, or did not consider, all of the hazards associated with working in the elevator shaft. The investigation also found that the elevator instruction manuals did not provide detailed and unambiguous safety guidance; and that critical safety procedures had not been implemented.

At about 1750 on 27 January 2007, British Mallard's crew attempted to repair an elevator fault before they finished work for the day.

The electrical technician made some adjustments to the second deck elevator landing doors and, at about 1800, he stepped into the elevator shaft.

At the electrical technician's request, the second deck elevator landing doors were allowed to close behind him. When the doors closed, the landing door safety circuit was completed and the elevator control system then reset itself.

It is likely that someone then attempted to use the elevator and did not notice the 'do not operate' signs that had been placed on the elevator doors and was unaware that the elevator was not to be operated.

The elevator car then started to move upwards. Its movement was eventually obstructed by the electrical technician and the resultant damage to the elevator car caused it to stop.

The ATSB has reported safety action already taken and issued one safety recommendation and two safety advisory notices with the aim of preventing similar accidents.

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