From flight attendant to human factors safety investigator, Indonesia’s Ucu Suherman has already helped halve the death toll resulting from one of her country’s most popular events.

Ucu is in Australia to attend an Australian Transport Safety Bureau’s Human Factors for Transport Safety Investigators course in Canberra and a psychology symposium in Adelaide.

She is proud of her work in helping to make the Lebaran holiday period safer for Indonesians.

Lebaran is one of Indonesia’s major national holidays, lasting several days after the fasting ritual of Ramadhan. More than 30 million people travel—mostly by road—to Jakarta, congesting the city’s vehicular arteries.

Ucu, 37, says the Indonesian Government and its National Transportation Safety Committee (NTSC), developed messages focusing on driver fatigue to reduce the injury and death toll.

“In 2014 there were 3888 accidents with 714 deaths and 1939 people seriously injured,” Ucu said.

“After our campaign this year using messages about fatigue, the number of accidents was 1947. The death toll was reduced to 366 with just 634 serious injuries. This was a big improvement.”

After graduating from university in 2002 with a psychology degree, Ucu started working as a flight attendant for Merpati Nusantara Airlines. She was soon asked to join the safety division as a human factors officer. A year later Ucu was invited to conduct training for flight attendants.

“This was a very busy time for me but I enjoyed the training work very much,” she said.

Keen to further her experience, Ucu took up a position with Lion Air Group as flight attendant instructor, where she worked for five years before being asked to become the safety management systems manager.

An opportunity to join the NTSC in 2016 as a safety investigator was too good to refuse. Ucu’s work at NTSC includes not only Human Factors input to investigations, but also training for other NTSC staff and Indonesian aviation industry personnel.

“I have worked at the NTSC for only seven months but I love the human element of this work,” she said. “Seeing what happens beyond the system—the human factors perspective is very interesting.”

One of only three female safety investigators at the NTSC, Ucu is in Australia to benefit from the Australian government Indonesia Transport Safety Assistance Package (ITSAP). Her colleague Apib Prayogi was in Canberra in September.

The ATSB's contribution to ITSAP is to deliver training and support for investigators from the NTSC to enhance transportation safety for the people of Indonesia and Australian travellers to Indonesia.

Ucu had an opportunity to experience a uniquely Australian experience while here—the Melbourne Cup. But the highlight of her day was eating lamingtons and pavlova. “I love it,” she said.

Aircraft passengers are being urged to take extra care of their electronic devices onboard aircraft following two separate safety incidents involving crushed smartphones on 21 October 2016.

In both instances, the business-class passengers inadvertently crushed their phones while moving their seats, after their devices were accidently dropped down the side of the seat.

The first incident occurred when the aircraft was descending into London. As the cabin crew was serving the passenger, the seat was moved electronically, crushing the passenger’s smartphone and resulting in the phone emitting smoke.

The phone had been on charge at the time. Once the charging cable was removed, the smoke started to dissipate. The phone was placed in a metal bin and covered with water.

In a second incident, while flying to Sydney, a passenger asked a cabin crew member to help retrieve his phone from the seat after it got stuck there while he was sleeping.

The phone was damaged during the retrieval process, and it started to make intermittent bright flashes and a hissing noise.

The crew quickly placed the phone in a steel jug of water with no injury or damage to the aircraft.

The operator is undertaking a range of safety actions to prevent future occurrences. This includes changes to safety briefings reminding passengers not to move their seats when their devices have been lost and to ask a crew member to recover the phone.

These two incidents follow other similar occurrences investigated by the ATSB:

• On 21 June 2016, a passenger’s personal electronic device caught fire while flying from Los Angeles to New York in the US.
• On 15 May 2016, cabin crew located a passenger’s electronic device tightly wedged in the seat mechanism after it emitted smoke during a flight from Sydney, Australia to Dallas in the US.

In all these incidents, the cabin crew provided an effective response to an emergency situation.

Passengers should be reminded of the following:

• Phones should be kept in an approved stowage, unless in use
• Passengers should locate their phone before moving powered seats
• In the event that a passenger cannot locate their phone, they should refrain from moving their seat and immediately contact a cabin crew member
• Passengers should always follow the directions of cabin crew.

The Australian Transport Safety Bureau (ATSB) will boost its investigation capability with the imminent deployment of a new remotely piloted aerial system (or drone).

The use of drones in safety investigations has the potential to significantly reduce costs and improve investigator safety.

The ATSB’s drone project manager, Aaron Holman, says the organisation has been monitoring the emerging technology since 2012.

“The technology has reached a point where we believe it can be usefully deployed to accident sites to assist our investigators and investigations,” Mr Holman said.

Benefits of the drone technology include safety, mapping and recording.

“The biggest benefit is being able to survey an accident site quickly and accurately—the entire accident site,” Mr Holman said.

“We can inspect by drone before sending our investigators in. We can ensure the site is safe.

“We’ll get still images and video which we’ll be able to integrate into our investigation reports, which will make them more interactive and more engaging. We hope to be using the drone before the end of the year.”

Drones, however, do have their limitations.

“They may be less useful in densely forested areas or confined spaces,” Mr Holman said. “They can’t really be used in rain and there are performance limits in windy conditions.”

After watching a demonstration of the drone’s photographic and mapping capabilities north of Canberra recently, ATSB Chief Commissioner Greg Hood is keen to see the technology deployed in the field.

“This will be a useful addition to our investigation armoury and a cost-effective solution across aviation in particular, but also maritime and rail sectors,” Mr Hood said.

As well as lowering the risk to ATSB investigators, there is a significant cost efficiency over mobilising aircraft such as helicopters.

“Although we sometimes piggyback on police aerial resources to assist with our investigations, the cost of assessing an accident site via helicopter can be high,” Mr Holman said. “Using a drone will be cheaper, easier to use and more flexible.

“We’ll be able trace accident flight paths far more accurately and be able to identify strike marks on a tree, for example. This was problematic before this technology became available.”

After testing is completed, the ATSB is likely to deploy drones from its offices in Canberra, Brisbane, Adelaide and Perth.

The original forecast at the time of departure for the intended destination of Adelaide, did not predict fog. During the flights, fog formed at Adelaide, preventing a normal landing. Both crews considered conducting an auto land at Adelaide but with better weather expected at Mildura they both chose to divert, only to find deteriorating conditions there too had left them with limited options.

As a result, both crew landed below minima at Mildura.

On 18 June 2013, two Boeing 737 aircraft, VH-YIR operated by Virgin Australia Airlines Pty. Ltd. as Velocity 1384 and VH-VYK operated by Qantas Airways Ltd. as Qantas 735, were on scheduled flights to Adelaide, South Australia.

On nearing Adelaide, the forecast improvement in weather conditions had not occurred and as a result, both aircraft commenced a diversion to Mildura, Victoria. Upon arrival at Mildura, the actual weather conditions were significantly different to those forecast, in particular with visibility reduced in fog.

The flight crew of Qantas 735 conducted an instrument approach and landed below minima. The flight crew of Velocity 1384 also conducted an instrument approach and landed below minima in fog and with fuel below the fixed reserve.

The ATSB found that the weather deterioration at Adelaide did not appear on the forecast when both aircraft departed their respective ports and furthermore the forecast duration of the fog in the later, amended forecast showed a clearance time earlier than actually occurred. This meant that Qantas 735 continued to Adelaide with the expectation that the fog would clear prior to their arrival, which did not occur. It also influenced the decision making of the Virgin Australia flight watch personnel, who did not pass this weather to the flight crew of Velocity 1384.

In relation to the weather at Mildura, the ATSB found that the deterioration was significantly worse than originally forecast. This resulted in the need for both Qantas 735 and Velocity 1384 to land in conditions that were below minima. The ATSB identified that both flight crew uploaded sufficient fuel for the originally-forecast conditions in accordance with their operators’ fuel policy and the Civil Aviation Safety Authority requirements.

The ATSB also found that in certain weather patterns and at certain locations, fog is both rare and difficult to forecast reliably.

In addition, the ATSB noted that the industry expectation for the provision of flight information services was not aligned with that provided by Airservices Australia (Airservices). Further, it was identified that in certain circumstances, pilots will not be made aware of a deterioration of weather at an airport that has an Automatic Weather Information Service or other Automatic Broadcast Service. These services did not provide for the recognition and active dissemination of special weather reports (SPECI) to pilots, thereby not meeting the intent of the SPECI alerting function provided by controller-initiated flight information service.

In response to this occurrence, Airservices advised that they would work with the Bureau of Meteorology to explore feasible options to provide information on significant deteriorations in weather conditions to address the very high frequency radio range limitations of the automated broadcast services. In the meantime, Airservices has updated the Manual of Air Traffic Services to ensure dissemination of weather information from locations with an Automatic Weather Information Service should that service be unavailable.

The Bureau of Meteorology advised of various system changes and improvements in response to this occurrence. This included to equipment used in forecasting.

Virgin Australia Airlines Pty. Ltd. (Virgin) advised of a review and benchmarking exercise as part of its examination of this occurrence. This resulted in enhancements to Virgin’s flight planning and flight following policies, re-organisation of the flight following section and expansion of communication infrastructure across the Virgin fleet. In addition, Virgin’s pilot weather requirements have been clarified and enhanced.

In response to this occurrence the ATSB issued a safety recommendation to Airservices. This recommended that Airservices, as the issue owner, work in collaboration with the Bureau of Meteorology to instigate a system change to reinstate the alerting function of SPECI reports currently not available through an Automatic Broadcast Service.

Safety message

Pilots are reminded of their responsibility for collecting all relevant information to support in‑flight decision making. This includes weather and operational information for the destination, which should be considered prior to a decision point or point of no return.

It is important that pilots understand what will be provided under Airservices’ provision of flight information service and that they are also able to request weather and operational information from air traffic control. In addition, pilots should note the potential benefits of informing the controller of a non-normal situation. These include increased monitoring and support as required and the potential to reduce pilot workload in stressful situations.

Read the final report: Landing below minima due to fog involving Boeing 737s, VH-YIR and VH-VYK, Mildura Airport, Victoria, on 18 June 2013

When responding to accidents and serious incidents, investigators with a wide range of skills and qualifications are deployed in teams to carry out the investigation and discover what went wrong.

Most investigations (other than short investigations) involve deployment of a small team to the incident site to study the damaged or destroyed transport vehicle and other physical evidence at the site. The team also conducts initial interviews with survivors, witnesses, and people such as the operator and maintenance staff and family of the crew and passengers. Investigators will deploy to the site as soon as possible to avoid any loss of evidence that can occur over time, and also to allow quick clearance of accident sites.

The team will conduct checks on maintenance of the transport vehicle and material from the site may be brought to the ATSB’s technical facilities in Canberra for close study and technical analysis.

ATSB transport safety investigators have a wide range of skills and qualifications. Many of our investigators have had careers in the transport or defence industries before joining the ATSB. Among their number are pilots, air traffic controllers, psychologists, master mariners, train drivers engineers—from many disciplines including materials, electronics, avionics, rail, marine, aeronautical, and mechanical. In recent years we have also recruited graduates directly from university.

Many vehicles are fitted with data recorders, similar to the ‘black boxes’ that people associate with aircraft.  Voyage data recorders on marine vessels, cockpit voice recordings, flight data recorders as well as train loggers, may provide data which will be downloaded and analysed using specialised equipment and processes in the ATSB’s technical facilities. Often, other electronic evidence is gathered from electronic chips in vehicle systems and components—these devices can reveal much about the performance of a transport vehicle and its systems in the period leading up to the accident. Investigators will also gather devices such as GPS units, tablet computers and smart phones found in wreckage, which can provide valuable information such as the route taken. Air-traffic control data and in-port vessel management systems are valuable sources of data that often reveal movement leading up to an incident.

Where necessary, investigators will collaborate with academics and international specialists when additional expertise or advice is required.

In the office, the team will compile their evidence, conduct a thorough analysis and form conclusions about what might have led to the occurrence. A formal report is written and initially released to the directly involved parties, who are given the chance to comment on the factual accuracy of the report before it is completed. The final report is then approved by the Commission and formally published.

Published reports are available from www.atsb.gov.au

The ATSB is reminding pilots of the dangers of aerodynamic stall, after a student pilot and instructor were killed after their aircraft collided with terrain.

The accident occurred on 9 November 2012 near Lismore Airport, New South Wales where the student and instructor were conducting circuit training flights in a SOCATA TB 20. The ATSB found that while making a left turn in the circuit, an aerodynamic stall occurred, resulting in a significant left-wing low and nose-down attitude in close proximity to the terrain. The aircraft collided with terrain in a paddock, about 3 km south of Lismore Airport. Both occupants received fatal injuries, and the aircraft was destroyed by the impact and an intense fuel-fed, post-impact fire.

...the aircraft stalled at such a low altitude that they were unable to recover fully to controlled flight before the aircraft collided with terrain.

Either because of insufficient warning or lack of time to react, the instructor was unable to prevent the stall from occurring. Although it appeared that a stall recovery was commenced, the aircraft stalled at such a low altitude that they were unable to recover fully to controlled flight before the aircraft collided with terrain.

The ATSB also found that the aircraft’s engine contained crankcase through bolts from a different engine manufacturer that were installed in the engine prior to the aircraft’s importation into Australia and were probably unapproved for use in that engine. Although these bolts did not contribute to the accident, their installation meant that the continued safe operation of the engine could not be assured.

The accident highlights the need for pilots to minimise the risk of aerodynamic stall, particularly when in proximity to the ground, such as during take-off and landing.

In addition, aircraft owners and maintainers should ensure that all parts fitted to their aircraft are appropriately approved for the application.

Read the final report: Loss of control involving SOCATA TB 20, VH-HBB, 3 km south of Lismore Airport, New South Wales, on 9 November 2012