The ATSB has found it is likely that some passive level crossings in the Northern Territory, Queensland, Western Australia and South Australia that are controlled by 'Stop' signs and are used by high combined gross mass road vehicles may have deficient sighting distances.

The Australian Transport Safety Bureau has released a supplementary report on this potential problem as part of its continuing investigation into the 12 December 2006 collision involving The Ghan on the Fountain Head Road level crossing at Ban Ban Springs, NT.

The Fountain Head Road level crossing signage at Ban Ban Springs directs road users to stop at the level crossing and to give way to trains that may be either on or approaching the level crossing at a line speed of up to 115 km/h. The road intersects the rail line at 90 degrees in a north-south direction with a slight rising grade for vehicles approaching from the north and with slight road curvature either side of the level crossing.

While not a factor in The Ghan collision, ATSB investigators identified that the time taken for larger road trains commonly used in the Northern Territory, Queensland, Western Australia and South Australia to traverse level crossings, and the available sighting distance, may be a safety issue.

The ATSB organised a timing trial to test the adequacy of the level crossing sighting distances by measuring a range of clearance times for the largest road-train combinations which routinely use the Fountain Head Road level crossing at Ban Ban Springs (and indeed similar crossings in the NT, and other states).

B+2A Road-Train Combination

Tests conducted on 53.5 m long B+2A road-trains at the Fountain Head Road level crossing, Ban Ban Springs, found that the theoretical models used to calculate sighting distance were likely to be inadequate for the truck configuration tested. It is probable that sighting distances at other level crossings controlled by 'Stop' signs, used by high combined gross mass road vehicles, may be similarly deficient and more research is needed to accurately assess this risk.

Accordingly, the Australian Transport Safety Bureau has advised that State and Territory road transport authorities and rail regulators should consider the implications of this safety issue and take action where it is considered appropriate.

Read the report: Level Crossing Collision between The Ghan Passenger Train (1AD8) and a Road-Train Truck, Ban Ban Springs, Northern Territory, on 12 December 2006

The ATSB has released a 500-page final report into Australia's worst civil aviation accident since 1968. The report spells out contributing safety factors involving the pilots, the operator and the regulator as well as other safety factors, and has made further recommendations to improve future safety.

An Australian Transport Safety Bureau team of a dozen investigators has taken nearly two years of painstaking investigation to complete the final report since the tragic accident on 7 May 2005 which killed both pilots and all 13 passengers. Three ATSB factual reports, a research report and ten safety recommendations were released in the interim. The investigation was complicated by an inoperative cockpit voice recorder, no witnesses, and the extent of destruction of the aircraft.

The ATSB found that a mechanically serviceable Metro 23 aircraft operated by Transair was unintentionally flown into South Pap ridge in poor weather during a satellite-based instrument approach, probably because the crew lost situational awareness in low cloud.

The experienced 40-year old pilot in command was very likely flying the aircraft but was reliant on the 21-year old copilot to assist with the high cockpit workload. He knew the copilot was not trained for this type of complex instrument approach. Despite the weather and copilot inexperience, the pilot in command also used approach and descent speeds and a rate of descent greater than specified in the Transair Operations Manual, and exceeded the recommended criteria for a stabilised approach. The pilot in command had a history of such flying.

The investigation found significant limitations with Transair's pilot training and checking, including superficial training before pilot endorsements and no 'crew resource management'. Deficiencies also existed in the supervision of flight operations and standard operating procedures for pilots. There were also significant limitations in the way Transair managed safety, Transair's management processes and because the chief pilot was over-committed with additional roles as CEO, the primary check and training pilot, and working regularly in Papua New Guinea.

The regulatory oversight was also not as good as it could have been, especially when Transair moved from a charter to a regular passenger transport operator and was growing rapidly in Australia. In addition to the serious pilot and company contributory factors, if CASA's guidance to inspectors on management systems and its risk assessment processes had been more thorough, the accident may not have occurred.

The ATSB investigation also identified a range of other safety issues which could not be as clearly linked to the accident because of limited evidence. These included shortcomings in the design of the navigation chart used and the possibility of poor crew communication in the cockpit.

The ATSB hopes that this final report will assist the families and friends of those who perished in this tragedy to move towards closure, and will lead to further improvements in aviation safety to ensure that such an accident never happens again.

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 high-pressure oxygen system fire on board the roll-on/roll-off cargo ship Searoad Mersey, on 22 September 2006, occurred when an unsuitable replacement hose fitted to the system ignited. The ship's trainee engineer was hit in the head by the gas pressure regulator and received burns to his face, head and arms.

At about 1540 on 22 September 2006, the trainee engineer was preparing the fixed oxy-acetylene system for a small hot-work job when two of the oxygen system's high-pressure hoses, and the oxygen regulator, exploded in a flash fire.

It is probable that, when the trainee engineer opened the cylinder's valve, the heat created by the compression of the oxygen in the line ignited the lining in one of a pair of replacement high pressure hoses that had been recently fitted to the system.

The replacement hoses were not designed for use in a high-pressure oxygen system. The hose liners had a low ignition temperature, the hoses were probably assembled in an oily environment, and the hose material did not comply with the appropriate standards for high pressure oxygen hoses.

The ATSB report also found that the hose assembler who supplied the hoses was not aware of any special requirements for high pressure oxygen systems when he assembled the hoses. Similarly, the ship's engineers were not aware of all of the hazards associated with high pressure oxygen systems or of the standards required for them.

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

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

The ATSB has found that the use of starboard instead of port helm led to the grounding of the Singapore registered woodchip carrier Crimson Mars in the River Tamar on 1 May 2006.

The Australian Transport Safety Bureau investigation found that an unsuitable conning position, ineffective bridge resource management and the distraction caused by the use of a mobile telephone may have contributed to the helm being applied the wrong way. It was also found that inadequate monitoring of the helm orders and their execution led to the error not being detected in time to prevent the grounding.

At 1400 Australian Eastern Standard Time on 1 May, Crimson Mars, nearly fully loaded with a cargo of woodchips sailed from Bell Bay with a pilot on board. The sky was cloudy, visibility was clear with a light south-easterly wind and the tide was flooding. The ship's master and third mate were on the bridge for the pilotage and a helmsman was steering the ship as instructed by the pilot.

The pilotage progressed as intended by the pilot until about 1440 when a turn to port around Garden Island, a critical part of the passage, was being executed. During the turn, starboard instead of port helm was applied for approximately one minute. By the time the error was detected and maximum port helm applied at about 1441, grounding was inevitable. Soon after, the pilot ordered both anchors to be let go and the main engine to be run at emergency full astern in an attempt to reduce the effects of the impact. At 1442, Crimson Mars grounded on Long Tom Reef and shuddered to a stop as the port anchor was let go and the main engine was run astern.

At 1446, the ship, with its engine running astern, moved off the reef and refloated. The pilot ordered the anchor to be retrieved. This resulted in the failure of the port windlass and the anchor cable running out to its bitter end, which held. The ship remained at anchor off Garden Island until two tugs that had been called to assist were made fast at 1605. The anchor cable was then cut, just above the hawse pipe, by the ship's crew using gas cutting equipment and left in the river together with the port anchor. The ship returned to the Bell Bay anchorage so that an assessment of the damage could be made. No oil spill or other pollution resulted from the incident.

The ship was severely damaged with its bulbous bow holed and pushed in, and ballast water tanks forward were breached. The damage could not be repaired in Bell Bay and over the next few days contingency arrangements were agreed upon by the ship's Flag State, classification society and the Australian Maritime Safety Authority.

On 12 May, with contingency arrangements in place, Crimson Mars sailed for Taiwan to unload its cargo and undergo permanent repairs in dry dock. The ATSB investigation also found that the attempt to retrieve the port anchor and later the cutting of the anchor cable were necessarily hazardous operations. The ship's and the ports procedures for contingency planning and emergency response were considered inadequate. The ATSB has made several safety recommendations with the aim of preventing similar incidents in the future.

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 passage monitoring resulted in the Vanuatu registered offshore tug/supply ship Massive Tide grounding on Rosemary Island, off Dampier Western Australia, at 0445 on 29 August 2006.

The Australian Transport Safety Bureau investigation found that fatigue probably impaired the performance of both the master and the officer of the watch and that the officer of the watch did not adequately monitor the ships progress during the voyage from the jack-up drill rig Ensco 106 to Dampier on the morning of 29 August.

At 0100 on 29 August, Massive Tide departed the drill rig Ensco 106 at a speed of 9.8 knots and on a heading of 129 degrees, a heading that would take it directly to Rosemary Island, rather than the Dampier Sea Buoy as intended.

At 0200 and 0400, the officer of the watch recorded the ship's GPS position in the deck logbook, but did not plot either position on the navigational chart.

At 0445, Massive Tide grounded on the shoals approaching the western shore of Rosemary Island. The rest of the crew were called out and checks of the ship, its machinery and the surrounding area revealed that no damage or pollution had occurred.

Immediate attempts to refloat the ship were unsuccessful and plans were put in place to try again on the next high tide. At 1035, the ship floated free without assistance.

The ATSB report further concludes that the ship's master did not ensure that the bridge watchkeepers routinely followed his instructions and company procedures; and that the procedures and practices in place on board Massive Tide did not ensure that the levels of watchkeeper fatigue were effectively managed.

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

The ATSB has found that neither the harbour pilot nor the ship's crew adequately considered the ships speed or its movement in the prevailing conditions and this led to the Indian oil tanker Desh Rakshak grounding near Point Lonsdale.

The Australian Transport Safety Bureau investigation found that the depth of water below the ship's keel was less than the bridge team had anticipated; and the Port Phillip Sea Pilots procedures did not give effective guidance to the pilot when deciding whether, or not, to pilot the ship from sea to the Melbourne outer anchorage in the prevailing conditions. It was also found that the inadequate application of bridge resource management led to the ship's bridge team having little effective input during the pilotage passage.

Desh Rakshak arrived off Port Phillip on the morning of 4 January 2006, with about 80 000 tonnes of crude oil cargo on board, and at 0800 a pilot boarded the ship for the transit from sea to the Melbourne outer anchorage.

The pilot planned to enter the port to the west of the track marked by the main leading lights, to keep the ship out of an opposing tidal flow for as long as possible. When the ship was almost abeam of Point Lonsdale Lighthouse, the pilot thought he could see the high and low main leading lights just open to the west. This indicated to him that the ship was on the edge of the Great Ship Channel. However, the ship was further to the west than the pilot thought.

The ship continued the transit and anchored at 1154. No one on board the ship observed anything that might have suggested that the ship had grounded at about 0825, when it was abeam of Point Lonsdale.

At about 1245, the ship's crew discovered that the level in the lower fore peak water ballast tank was rising. An inspection of the tank revealed that the ship's hull had been holed.

The ship berthed in Geelong on 5 January and temporary repairs were carried out before it sailed for Singapore on 19 January, where it was dry-docked for permanent repairs.

The ATSB is pleased to report safety action already taken and has made several safety recommendations with the aim of preventing similar events.

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

The ATSB has found that insufficient train braking and inadequate warning distance contributed to a collision between a track mounted excavator and a freight train at Inverleigh, Victoria on 25 September 2006.

The Australian Transport Safety Bureau investigation established that the collision occurred because the train driver's initial brake applications approaching the work site were too little too late and that the outer flag person protecting the worksite was not positioned far enough away from the site given the anticipated train traffic, the line speed and the descending gradient.

The ATSB concluded that 'in these circumstances there was an unacceptably high risk of a collision'.

The ATSB report makes recommendations to the train operator and the track manager with the aim of protecting track-work sites from similar accidents.

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

The ATSB has been successful in downloading key data from the flight data recorder (FDR) of the Garuda 737 accident aircraft but the cockpit voice recorder (CVR) has not yet been able to be downloaded.

The Australian Transport Safety Bureau (ATSB) is assisting the Indonesian National Transportation Safety Committee (NTSC) with Indonesias investigation into the factors which led to the accident in accordance with Annex 13 to the international Chicago Convention under which the Indonesian NTSC is in charge of the safety investigation and the ATSB is Australia's 'accredited representative'.

In addition to the ATSB's three on-site investigators, as part of this assistance, four specialist ATSB investigators in Canberra have been working since Friday afternoon, together with other staff, to download data from both the CVR and the FDR recovered from the accident aircraft.

The ATSB has been authorised by the NTSC to report that, despite the damage to the two recorder 'black boxes', useful data has been recovered from the FDR. The flight data recording system is designed to record over 200 engineering parameters. The recovered data covers the previous 53 flight hours of aircraft operation, and includes substantial data from the accident flight.

The ATSB has this afternoon provided to the NTSC some initial FDR data including the aircraft's speed, vertical acceleration, flap settings and the wind experienced in the accident sequence.

ATSB investigators have been working with the US-based CVR manufacturer, Honeywell, to download data from the CVR but an ATSB investigator now needs to take the CVR module to Honeywell in Seattle to attempt recovery because all normal specialist recovery techniques have proved unsuccessful.

At the NTSC's request, the ATSB is prepared to continue to analyse the recovered FDR data over the coming weeks and months as the investigation progresses and to prepare a full accident animation.

It is for the NTSC to authorise the release of any information derived from the recordings as it becomes available and is verified by the investigation team.

The ATSB has reviewed safety information on a Qantas 747 tyre burst incident on take-off at Singapore Airport on 8 March 2006 and agrees with the Singapore and German authorities that there was no safety concern warranting a major investigation.

In March 2006, specialist investigators in Australia, Singapore and Germany determined after preliminary investigation that a full investigation was not warranted. From September 2006, the ATSB and Singapore Air Accidents Investigation Branch reviewed detailed material received with the full cooperation of Qantas and again determined a major investigation was not required.

While tyre burst incidents can be potentially very serious, in the Singapore incident the aircraft crew was not aware of any damage to the aircraft as a result of the loss of one of its 18 tyres on take-off until about 6 hours into the flight to Frankfurt when a problem with the number 4 hydraulic system became apparent. The crew managed the problem and landed safely in Frankfurt where the damage to the aircraft wing-to-aircraft body fairing (fibreglass non-structural) outer skin was seen. Repairs were made and appropriate safety authorities notified.

Under international aviation law (the Chicago Convention and its Annex 13) the country of occurrence is responsible for any safety investigation. Singapore assessed that the occurrence was not an accident or serious incident as defined by Annex 13 and decided not to investigate.

Modern passenger aircraft have many redundant safety systems and while damage to the aircraft's fairing may look very worrying to the general public, it was superficial and did not affect the structural integrity of the aircraft. There is also no suggestion of a systemic problem with 747 tyres or the aircraft's hydraulic systems.

The ATSB investigates aircraft accidents and serious incidents in Australia and has to apply judgement as to which of the more than 7000 occurrences reported annually warrant investigation within a budget that allows for about 30 larger and 60 smaller new investigations. Similar judgements are made by other professional investigation bodies around the world.

The ATSB investigates all fatal accidents (except sport aviation) which are overwhelmingly in the general aviation sector and all accidents involving international carriers in Australia. A number of recent ATSB investigations have involved aircraft in the Qantas group, which is in line with Australian passenger airline activity levels.

After further review of the circumstances of the tyre burst, the ATSB agrees with the Singapore authorities that a major investigation would not contribute to future safety in a manner that would be likely to lead to an improvement in 747 or tyre design, manufacture or operations.