The primary mechanism for the prevention of carbon monoxide exposure to aircraft occupants is to carry out regular inspections of piston-engine exhaust systems to identify and repair holes and cracks, and to detect breaches in the firewall between the engine compartment and the cabin.
What happened
On the afternoon of 31 December 2017, the pilot and five passengers of a DHC-2 Beaver floatplane, registered VH-NOO, boarded the aircraft for a charter flight from Cottage Point to Rose Bay, New South Wales. The aircraft taxied for about 7 minutes. Shortly after take-off, the aircraft deviated from the standard flight path, stopped climbing, and entered a confined area (Jerusalem Bay) below the height of the terrain. The aircraft continued along the bay before making a very steep right turn and colliding with the water. All on board were fatally injured and the aircraft destroyed.
Why did it happen
Toxicological testing found that the pilot and two of the passengers had elevated levels of carbon monoxide (CO) in their blood. The levels detected were likely to have adversely affected the pilot’s ability to control the aircraft during the flight. Carbon monoxide is a colourless, odourless and tasteless by-product found in the exhaust gases of piston-engines.
The ATSB conducted a detailed examination of the engine exhaust collector-ring and found evidence of pre‑existing cracking and exhaust leakage into the engine bay.
In addition, three out of eight bolts used to secure the magneto access panels in the firewall under the instrument panel in the cabin were also found to be missing. Any breach in the firewall can allow gases to enter the cabin from the engine bay.
: The thorough inspection of piston-engine exhaust systems and the timely repair or replacement of deteriorated components is the primary mechanism for preventing carbon monoxide exposure. This, in combination with the assured integrity of the firewall, decreases the possibility of carbon monoxide entering the cabin. The ATSB reminds maintainers of the importance of conducting detailed inspections of exhaust systems and firewalls, with consideration for potential carbon monoxide exposure.
The ATSB advises all commercial balloon operators utilising vehicle‑assisted deflation to review their current operational practices with the aim ofmitigating the safety risks associated with the procedure.
What happened
On 16 March 2019, two passengers were seriously injured when the basket of a Kavanagh B‑400 hot‑air balloon tipped over during vehicle-assisted deflation.
Prior to the accident, the balloon, operated as a scenic charter flight, landed without incident at a private property near Coldstream, Victoria.
Due to a lack of wind and the large size of the envelope, the crew elected to use the retrieval vehicle to assist by pulling the envelope over (by the crown line) during the deflation.
During this process, with 16 passengers and the pilot on board, the vehicle assisting inadvertently pulled the basket over, seriously injuring two passengers.
This accident was the third time since 2016 where occupants of a commercial balloon were injured as a result of similar events during a vehicle‑assisted deflation.
Why did it happen
During the vehicle-assisted deflation, the pilot put down the handheld radio to operate the vent line. The second ground crew member was not in an observable position for the driver, which led to a communications breakdown and limited the pilot and the second ground crew members’ opportunity to promptly command the driver to stop to avoid the basket tipping.
In addition, during the procedure, the majority of passengers were not in the landing position when the basket tipped, which increased their probability of injury.
The operator began using the vehicle-assisted deflation method around 12 months prior to the accident. At this time the operator did not conduct a risk assessment and had not developed procedures for safely conducting vehicle‑assisted deflation. This contributed to the crew’s lack of awareness of the risk of the basket tipping during the deflation.
: The ATSB advises all commercial balloon operators utilising vehicle‑assisted deflation methods to review their current operational practices in light of the findings in the ATSB investigation report AO-2019-014 with the aim of mitigating the risks associated with the procedure. This review should be conducted with emphasis on:
reducing the risks associated with a communications breakdown between the pilot and vehicle driver, and
include a review of the positioning of occupants within the basket to minimise the likelihood of injury if the basket tips during the vehicle‑assisted deflation.
Each year, thousands of safety occurrences involving Australian aircraft and foreign‑registered aircraft operating in Australia are reported to the Australian Transport Safety Bureau (ATSB).
This report is part of a series that aims to provide information and statistical data to the aviation industry, manufacturers and policy makers, as well as to the travelling and general public, about these aviation safety occurrences. In particular, the data can be used to determine what can be learned to improve transport safety in the aviation sector.
The study uses information over the 10-year period from 2010–2019 to provide an insight into current and possible future trends in aviation safety.
This statistical report presents interactive web versions of all tables and graphs to allow the user to display aviation occurrence data in the format of their choice.
What the ATSB found
2019
In 2019, 220 aircraft were involved in accidents in Australia, with a further 154 aircraft involved in serious incidents (an incident with a high probability of becoming an accident). There were 35 fatalities from 22 fatal accidents. The number of fatalities was consistent with the average of the previous nine years (32.3 fatalities per year), and the number of fatal accidents was also consistent with its average (23.1 fatal accidents per year).
There have been no fatalities in scheduled commercial air transport in Australia since 2005.
2010 to 2019 accidents and incidents
Between 2010 and 2019, over 90 per cent of accidents and fatal accidents, and around 80 per cent of serious incidents, involved aircraft operating within the general aviation and recreational aviation sectors. In contrast, due to the more stringent reporting requirements for air transport operations, three‑quarters of reported incidents involved aircraft operating within commercial air transport.[1]
Considering all years in the period, the number of general aviation (GA) fatalities and fatal accidents decreased. The number of fatalities and fatal accidents within commercial air transport and recreation aviation remained relatively constant.
Since 2016, remotely piloted aircraft (RPA) have surpassed helicopters to become the second most common aircraft type involved in an accident. Further, the number of manned aircraft experiencing near encounters with an RPA also increased significantly over the study period.
2014 to 2018 accident rates
For the first time, statistics in this report have been organised around the type of aircraft activity being conducted, rather than the operational regulation. Due to the availability of activity data (departures and hours flown data), it was only possible to calculate accident and fatal accident rates over the five‑year period 2014–2018.
Over this period, test and ferry flights, recreational flights involving an aircraft registered with Recreational Aviation Australia (RAAus), followed by pleasure and personal transport, had the highest accident rates. Community services flights, followed closely by test and ferry flights, had the highest fatal accident rates. (However, as there was only one fatal accident involving an aircraft conducting community service flights between 2014 and 2018 there is a high level of statistical uncertainty associated with this rate). For aircraft types, recreational aeroplanes, followed by commercial balloons had the highest accident rates. Also, recreational aeroplanes had the highest fatal accident rate.
Commercial air transport
There were no fatalities within commercial air transport in 2019.
Over the full study period (2010–2019), more than half of all serious incidents and the majority of accidents and fatal accidents for commercial air transport operators involved aircraft conducting non‑scheduled activities, predominantly passenger transport charters. There were no identified increases or decreases in the number of accidents or serious incidents, however, the number of reported incidents for aircraft conducting scheduled international flights and commercial freight increased over the 10 years.
Between 2014 and 2018, around three‑quarters of the hours flown, and approximately one‑half of all departures, within commercial air transport, were operated by scheduled domestic or international operations. Over this period, there was a decrease in the hours flown by scheduled domestic operators; conversely, there was a proportionate increase in the hours for scheduled international operators.
Concerning activities within commercial air transport, passenger transport charters had the highest accident and fatal accident rates.
For specific aircraft types, within commercial air transport, balloons had an accident rate more than 10 times higher than for aeroplanes or helicopters. However, there was only one fatal accident involving a commercial balloon in the 2010 and 2019 timeframe.
Most commercial accidents and serious incidents were operational in nature (typically aircraft control and terrain collisions). The majority of incidents were environmental (mainly birdstrikes).
General aviation
In 2019, there were 17 fatalities in GA.
Over the 10 years, around one‑third of GA accidents and 44 per cent of fatal accidents involved aircraft conducting sport and pleasure flying. Aerial work accounted for a further 37 per cent of GA accidents and 32 per cent of fatal accidents. The number of GA accidents per year increased over the period, with aerial work identified as the primary contributor. Conversely, there was a decrease in the number of fatal accidents, resulting in a decrease of around one fatal accident or 1.4 fewer fatalities per year.
There was also an increase in the number of reported incidents for GA aircraft conducting instructional flying.
Between 2014 and 2018, around 40 per cent of GA hours flown were conducted within aerial work, with instructional flying accounting for a further 30 per cent. Sport and pleasure flying made up around 14 per cent.
The rate of GA accidents decreased over the five years 2014–2018. The main contributors to this decline were sport and pleasure flying, and own business travel. Additionally, there was also a decrease in the rate of fatal accidents for aircraft conducting sport and pleasure flying.
Between 2010 and 2019, there was an increase in the number of GA RPA accidents per year; this primarily resulted from a significant increase in the overall number of survey and photographic accidents.
Overall, there was a decrease in the accident rate for aeroplanes conducting GA flying. The main contributors to this decrease were identified as aeroplanes conducting sport and pleasure flying, and own business travel.
Over the 10 years, the majority of GA accidents, incidents and serious incidents were related to operational or technical issues. Additionally, the majority of fatal accidents were also attributable to operational issues.
Further, the number of GA operational-related accidents and serious incidents, per year, increased over the period. Instructional flying was the main contributor to this operational-related increase. Additionally, there was an increase in the number of accidents and serious incidents of a technical nature; largely attributable to aerial work operations (especially those conducted using an RPA).
Recreational aviation
In 2019, there were 18 fatalities involving an aircraft conducting recreational flying.
The accident rate for recreational flying decreased between 2014 and 2018, with Recreational Aviation Australia (RAAus) registered aircraft having the greatest contribution to this reduction.
Aeroplanes had the highest accident and fatal accident rates of any recreational aircraft type.
Similar to GA, over the full study period (10 years), the majority of recreational accidents and serious incidents were operational (mainly terrain collisions) or technical (primarily engine failure or malfunction) in nature.
The ATSB advises helicopter operators involved in hoist operations that improper stowage of the rescue hoist hook assembly can lead to excessive movement and accelerated wear of the wire rope. If undetected, the wear and associated damage can significantly reduce the cable integrity and operational safety of the hoist system. Should the cable fail while under load during operation, personnel being winched may sustain serious or fatal injuries.
Rescue hoist and hook assembly
Source: NSW Parks and Wildlife Service
What happened
On 4 February 2020, an Airbus Helicopters AS 350 B3 was being operated in support of NSW National Parks and Wildlife Service activities. Winching of personnel and equipment was being conducted when the operating crewman detected a technical issue with the wire rope cable of the hoist system fitted to the helicopter. The outer strands of the cable toward its termination into the hook assembly had loosened in respect of the inner core. Such loosening is known to occur during repeated short length winch deployment and retrieval cycles.
During that conditioning operation, and while under load, the cable fractured at the hook assembly, releasing the ‘dummy’ weight to the ground. There was no damage to the helicopter or injuries to personnel.
Why did it happen
Although the investigation is ongoing, the ATSB’s examination of the helicopter winch system identified that the wire rope cable failed near to the swaged ball-end that terminated into the hook assembly (see images below). Detailed technical examination identified that significant wear had occurred to the individual stainless steel wires comprising the cable, leading to reduced cross-section and an associated gross loss of tensile strength. The cable had accrued just 617 cycles of its 1,500 cycle life-limit. Examination of another rescue hoist from the operator identified similar wear damage had also occurred to that cable.
The ATSB identified that the wear associated with the cable failure probably occurred due to improper stowage of the hook assembly following hoisting operations. A hook that is not firmly seated or with the bump stop spring not sufficiently compressed can move during exposure to airframe vibrations and rotor downwash buffeting during normal helicopter operations. That movement can lead to accelerated wear of the hoist cable close to the ball-end fitting where it enters the hook assembly.
A rescue hoist cable that exhibits ongoing loosening of the outer strands, may have accrued damage from incorrect stowage following hoist operations. If the hook assembly is not firmly seated or is noted to be incorrectly stowed, during the required post-flight inspection particular attention should be paid to the ball-end of the cable for evidence of localised thinning or necking-down, broken wires or deformed strands. Such defects can reduce the cable integrity and compromise the safety of the rescue hoist system.
: The ATSB advises all helicopter operators and flight crew involved in rescue hoist operations to review their current operational practices to ensure hoist operation and hook stowage are in accordance with the hoist manufacturers’ published procedures.
In addition, the ATSB advises those operators, flight crew and maintainers to closely review the pre- and post-flight inspection requirements of the hook and cable assembly, along with any recurring scheduled maintenance of the hoist system, to ensure that they are completed in accordance with the manufacturers’ instructions.
Operating an amateur-built experimental helicopter outside the recommended design intent can potentially expose the helicopter to unintended stresses, and lead to the failure of critical components in-flight.
What happened
On 28 July 2015, the pilot and owner of an amateur-built Cicaré CH-7BT helicopter, registered VH-JEW, was conducting a ferry flight from Indee Station to Roy Hill Station, Western Australia. When about 8.5 NM north‑east of Roy Hill Station, the stabiliser assembly fractured leading to an in-flight break up and collision with terrain. The pilot was fatally injured and the helicopter was destroyed.
The ATSB examined the helicopter wreckage and identified that the stabiliser had separated in‑flight from the tail boom as a result of fatigue cracking of the stabiliser mount. This was the second fatal accident in Australia involving in-flight stabiliser separation on a Cicaré CH-7B helicopter (In-flight break-up involving Cicaré CH-7B, VH-SWQ, 43 km north-west of Barcaldine Airport Queensland on 12 May 2014 (AO-2014-086)).
During the course of the investigation, the ATSB found that a number of these amateur-built helicopters were being used for mustering operations, although the manufacturer stipulated that they were designed for recreational and sport use only. In addition, the ATSB established that both VH-JEW and VH-SWQ were fitted with external storage accessories, likely without the appropriate engineering assessment to ensure there would be no adverse effects on the performance, handling and structure of the helicopter. Although not the only contributors to the development of these accidents, operating outside the manufacturer’s design intent and limitations has the potential to induce stresses on the aircraft, leading to premature wear and possible failure.
Operating an amateur-built helicopter within the stated design intent and limitations is essential for safe conduct of flight. The ATSB advises owners/operators to be aware of the risks associated with operating amateur-built helicopters outside the limitations prescribed by the manufacturer. For example, mustering operations and the addition of unapproved modifications, can potentially produce unintended stresses on the airframe leading to the premature failure of components.
Accident experience has provided substantial evidence that the use of upper torso restraints reduces the risk of serious injuries to the head, neck, and upper torso of aircraft occupants, and they reduce the rate of fatalities for occupants involved in otherwise survivable aircraft accidents.
What happened
On 10 January 2017 a Cessna 172M, registered VH‑WTQ, departed Agnes Water aeroplane landing area (ALA), Queensland on a passenger charter flight to a beach ALA on Middle Island. While the pilot was conducting an airborne inspection of the beach, at a height of about 60 ft, the aircraft had a total engine power loss.
The aircraft impacted the beach and was destroyed. One of the rear-seat passengers was fatally injured and the other three occupants sustained serious injuries.
Wreckage of VH-WTQ (Source: ATSB)
Identified safety issue
The ATSB identified that the rear seats of VH-WTQ were not equipped with upper torso restraints (UTRs). An UTR is a shoulder strap or harness, and when fitted in addition to a lap belt makes an aircraft’s passenger restraint similar to a normal seat belt in a car. Had such restraints been fitted, the rear-seat passengers’ injuries would very likely have been less severe.
A substantial body of research has demonstrated that wearing UTR in small aircraft significantly reduces the severity of injuries compared to wearing only a lap belt. In particular, UTRs reduce the risk of head, neck and upper body injuries, associated with the person’s upper body flailing forward, and potentially striking seats, the side of the aircraft or other objects.
Currently, small aeroplanes manufactured after 12 December 1986 and helicopters manufactured after 17 September 1992 are required to have UTRs fitted for all seats. Based on the substantial body of research, there have been many recommendations over the years for UTRs to be fitted for all seats in small aeroplanes and helicopters manufactured before these dates (rather than just the front seats). These recommendations have been made by investigation agencies in the United States, Canada, the United Kingdom and Australia.
In addition, some aircraft manufacturers have published safety information letters and service bulletins, encouraging the fitment of UTRs to passenger seats that did not have UTRs fitted when the aircraft were manufactured. Options for retrofitting UTRs are available for many models of small aircraft.
: The Australian Transport Safety Bureau strongly encourages operators and owners of small aeroplanes manufactured before December 1986 and helicopters manufactured before September 1992 to fit upper torso restraints to all seats in their aircraft (if they are not already fitted).
In 2018–19, the ATSB continued to make a significant contribution to transport safety in Australia, thanks to the release of several substantial and high-profile investigation reports which contained valuable safety learnings for the aviation, rail and marine transport modes. During the year, we also entered into a strategic partnership with the Royal Melbourne Institute of Technology (RMIT) University, continued with our program of work to further improve our operational efficiency and effectiveness, and implemented an initiative to increase the number of Memoranda of Understandings (MOU) with transport industry associations.
There was much attention on the agency in September 2018 with the publication of the final report from our investigation into a King Air aircraft’s collision with a building in a retail precinct at Melbourne’s Essendon Airport in 2017 (AO-2017-024).
The investigation found the aircraft’s rudder trim was set incorrectly for take-off, resulting in a loss of directional control. The investigation drew upon the ATSB’s world-leading human factors capabilities, which resulted in safety messaging around the use of checklists as an essential tool for overcoming limitations with pilot memory and ensuring action items are completed in sequence without omission. This messaging highlights the ATSB’s approach to safety investigation, which is to ensure that all the lessons can be learnt to help stop accidents in the future.
On an international level, the ATSB’s contribution to safety was exemplified by the release of our final report from the investigation into a serious incident involving an ATR 72 turboprop airliner, which experienced an inadvertent pitch disconnect following an in-flight upset. This resulted in serious structural damage to the aircraft’s horizontal tailplane (AO-2014-032). The investigation into this complex event identified a number of safety factors, including some in relation to the continuing airworthiness of the aircraft, and aircraft certification standards.
As a consequence, the ATSB issued Safety Recommendations to the European Union Aviation Safety Agency to review the current design standards in consideration of the effect that dual pilot control inputs may have on the safe operation of an aircraft.
The ATSB is tasked with using its resources to improve transport safety for the greatest public benefit. We do this through systemic safety investigations that can lead to wide-reaching safety actions, thanks to our highly developed technical expertise and investigation analysis capabilities. I am proud of our capabilities and our program of continual improvement to best deliver transport safety outcomes.
Those capabilities were demonstrated when, during the year, the ATSB sponsored one of the premier psychology, human factors and crew resource management symposiums in the Asia–Pacific region. The ATSB also facilitated additional human factors training courses, adding to the more than 40 courses we have conducted since 2000 to educate those in a position to influence safety.
Partnership with Royal Melbourne Institute of Technology (RMIT) University
The ATSB is focused on ensuring its own people have the highest investigative capabilities and in educating others to achieve the same. If the public trusts that investigators, regulators and operators are identifying and managing safety risks, then there is confidence in safety of the transport system. A significant achievement that I recognise as realising this objective is the partnership entered into this year between the ATSB and RMIT University.
This partnership is part of a vision to create a centre of excellence in the field of accident investigation and transport safety in the Asia–Pacific region. Industries in Australia, throughout the Asia–Pacific and around the world are now able to obtain ATSB-sponsored qualifications in transport safety investigation. The partnership expects to extend to offering a Master’s-level qualification, as well as facilitating transport safety related research.
The first intake of students occurred on 1 July 2019 to study for a Graduate Certificate in Transport Safety Investigation. In 2020, a Diploma in Transport Safety Investigation will be offered before evolving into a Master’s program. Students will gain access to the best insights into the fundamentals of accident investigation, from attending an accident scene and gathering evidence, through to identifying human and other factors that contributed to an accident, investigation analysis and technical report writing.
Enhancing our efficiency
The ATSB is undertaking a program of work to enhance its operational efficiency and effectiveness. The ATSB’s interest is in making the greatest possible contribution to transport safety across the aviation, rail and marine modes of transport with its available resourcing. In particular, we are striving to make sure that our investigation reports are delivered in a timely manner.
During 2018–19, we benchmarked our performance against similar accident investigation agencies overseas. I am pleased to report that our performance is comparable with a number of internationally respected agencies. The median length of time we take to complete an investigation is slightly higher by comparison, but the ATSB is completing more per investigator than some of its comparators. We recently introduced amended key performance indicators to reflect the time it takes to complete complex investigations that look at in-depth systemic factors.
The Australian National Audit Office (ANAO) also audited our operational efficiency during the year. The ANAO found the ATSB has established key elements of an overall framework to promote efficient investigation processes. The ANAO also found that our efficiency had been declining with its use of resources, but acknowledged a number of actions that had already been taken by the ATSB to make improvements, including formalising aspects of its program-managed approach to investigations.
Our continued efficiency improvements will be supported by the large cohort of 17 new transport safety investigators who commenced with us in 2018. After completing their training and gaining further investigation experience, these recruits will take on higher levels of responsibility within the ATSB’s teams-based approach to investigation.
Building our networks
The ATSB recognises the value of being able to call upon the highest levels of expertise to best identify safety issues, and to that end, in 2018–19 we embarked upon an initiative to enter into Memoranda of Understandings (MOU) with transport industry associations. MOUs have now been signed with the Australian Federation of Air Pilots, the Australian and International Air Pilots Association, the Australian Licenced Aircraft Engineers Association, the Australian Association for Unmanned Systems, the Australian Certified Unmanned Aerial Vehicle Operators, Civil Air, and the Human Intervention Motivation Study Australia Advisory Group.
The ATSB will seek to further its reach by signing additional MOUs with industry associations and activating those relationships in 2019–20.
We are also deepening our partnership with the Defence Flight Safety Bureau (DFSB), which performs an equivalent role to us for Defence aviation. Both organisations are committed to investigating accidents and incidents, and analysing occurrence data under the ‘no-blame’ philosophy, with the sole aim of preventing recurrences. Under our MOU, the organisations can conduct joint investigations and participate in each other’s investigations. The relationship and knowledge sharing was strengthened during the year through a secondment of a DFSB investigator, who brought further human factors expertise to the ATSB.
Communicating with influence
The ATSB actively works to influence safety well beyond the publication of investigation reports. This year we held our inaugural FlySafe and RailSafe safety forums, while our SeaSafe marine safety forum will be held in 2019–20. These forums target safety messaging to receptive audiences from across the modes with the expectation that those audiences will share the safety messages with their industry-based colleagues. We have participated in a number of other industry-led safety conferences with this intent.
We have been active online using our website as an engaging information portal, as well as using our social media channels to publish information that is relevant to our stakeholders. In June, we published a video targeting emergency personnel on the potential dangers of inactivated rocket-deployed parachute systems on aircraft. The video has been viewed more than 2,600 times on YouTube, and more than 15,000 times on Facebook. We are a modern investigation agency that knows how to harness the available and emerging communication mediums to influence safety action.
We are focused on delivering the right content to traditional media, too. We have our own dedicated media studio for producing video and audio content for television and radio broadcasts. Conscious of the need to remember those who can inspire us to innovate, our studio is named after Macarthur Job OAM. ‘Mac’ was a pioneer of aviation safety messaging in Australia, editing the principal safety promotion publication of the Department of Civil Aviation’s Air Safety Investigation Branch – the Aviation Safety Digest. Known as the ‘crash comic’, we have further preserved this history by making the 150 editions of the digest (spanning 1953 to 1991) available online through the ATSB’s website.
Aviation
During the year, we completed 32 complex aviation safety investigations and 28 short investigations.
In addition to the aviation accidents previously highlighted, other significant aviation investigation reports released in 2018–19 include a runway excursion at Darwin Airport involving a Boeing 737 aircraft in December 2016 (AO-2016-166); a collision with terrain involving a Diamond DA40 aircraft near Southport, Queensland in September 2017 (AO-2017-096); and an in-flight upset involving a Boeing 747-400 aircraft near Hong Kong Airport in April 2017 (AO-2017-044).
The Darwin runway excursion resulted from factors that included a small increase in crosswind that led to a significant deviation of the aircraft from the runway centreline at a critical time during the final approach. The investigation highlighted the challenges of landing in darkness and poor weather conditions when landing on wide runways that lack centreline lighting. The operator and Darwin Airport have taken action to provide flight crews with information about the specific risks of approaches at the airport, while a safety recommendation made to the International Civil Aviation Organization has been referred to that body’s Aerodrome Design and Operations Panel for further study.
The collision with terrain of a Diamond DA40 aircraft near Southport resulted in fatal injuries to the instructor and student pilot on board. The aircraft entered a developed spin during manoeuvres consistent with advanced stall recovery training, which likely included intentional incipient spins. The spin continued until the aircraft collided with terrain. Although the investigation could not fully establish the reasons for the accident, the investigation identified varying interpretations of an ‘incipient spin’. The ATSB advised that operators and pilots should clarify with manufacturers the extent to which the early stages of a spin are permissible and ensure aircraft are always operated in accordance with limitations.
The in-flight upset of a Boeing 747 aircraft near Hong Kong resulted from factors that included the aircraft’s aerodynamic stall warning stick shaker activating a number of times and the aircraft experiencing multiple oscillations of pitch angle and vertical acceleration. The safety messaging from this investigation covered the need for comprehensive theory and practical training to ensure flight crews have a complete understanding of aircraft systems and they maintain effective handling skills. The training should provide flight crews with the knowledge to correctly configure the aircraft’s automatic flight systems and manual handling skills to respond adequately to in-flight upsets.
Rail
The ATSB completed seven complex rail safety investigations and two short investigations in 2018–19. Included in these releases is the ATSB’s investigation into the derailment of a coal train near Oakey in Queensland in July 2017 (RO-2017-007). It was found to be highly likely the underframe of a heavy road vehicle collided with rail infrastructure at a level crossing. Rail lines were displaced, causing the derailment and destroying about 300 metres of rail infrastructure. The accident highlights how vitally important it is for a driver in a road incident at a level crossing to report any damage and for rail infrastructure managers to ensure crossings are subject to regular and effective inspection.
We released our report from an investigation into another derailment involving an ore train near Walla in Western Australia in December 2015 (RO-2015-023). The derailment occurred due to a broken rail. A fracture of the rail was probably initiated by the rapid growth of a detectable, yet unidentified, fatigue-related defect. It is important that track maintenance and infrastructure fault detection is of a high standard to avoid similar occurrences.
A further derailment investigation involved a freight train near Dry Creek, South Australia in July 2017 (RO-2017-008). There had been a break in the section of track that was precipitated by a defect in the rail introduced in the manufacturing process 90 years ago. The rail break was not visually obvious, and when the freight train passed over it, the last three wagons derailed. The safety message in this accident was around the inspection of rail infrastructure. If an inspection cannot test or can only partly test rails, maintenance personnel must report the shortfall to highlight operational risk and the requirement for a timely supplementary examination.
Marine
The ATSB completed five complex marine safety investigations and four short investigations. The published reports included an investigation into a fall from height and serious injuries to crew members on board the Shanghai Spirit near Port Alma, Queensland in January 2017 (MO-2017-001). A mobile scaffold tower was used to conduct routine painting and touch-up work in the cargo holds. Two crew members conducted the work from the upper tiers and remained unsecured when the scaffolding was moved. The tower became unbalanced and toppled forward onto the deck. The safety message highlighted the importance of adhering to procedures that assure safety, as well as the value of effective supervision.
We released our report from the grounding of the Australian Border Force cutter Roebuck Bay on Henry Reef in the Great Barrier Reef in September 2017 (MO-2017-009). The vessel’s route plan had been amended during the passage planning process, resulting in the route being inadvertently plotted across Henry Reef. The cutter’s electronic chart display and information system (ECDIS) identified the reef as a danger to the planned route. However, the vessel’s officers did not identify the danger, either visually or using the ECDIS. The investigation highlighted that the safe and effective use of ECDIS as the primary means of navigation depends on the mariner being thoroughly familiar with the operation, functionality, capabilities and limitations of the specific equipment in use on board their vessel.
The report for the investigation into contact with a wharf by the vessel Madang Coast in Townsville, Queensland in November 2015 (MO-2015-007) was also released. As the Madang Coast moved alongside the wharf, the forward spring line slipped and could not be used during the manoeuvre, as the distance from the stern to the wharf was too far for the aft mooring party to throw any heaving lines ashore. The stern’s movement away from the wharf continued, making contact with another ship, while the bow made contact with the wharf. In this case, the risk management processes were not sufficiently mature nor resilient enough to effectively identify and mitigate risks in pilotage services. The investigation highlights the value of a safety management system that includes effective risk management processes.
Outlook
Appointed as the Chair of the International Transportation Safety Association (ITSA) in 2019, I will host an ITSA forum in Sydney in 2020. ITSA is a network of the heads of independent safety investigation authorities from around the world. The forum is valuable for sharing safety information and pursuing best practices in investigations. The ATSB will be seeking to continue to benchmark its performance against its peers to ensure that we are delivering optimal outcomes for transport safety in Australia.
Before ITSA, I will be releasing the ATSB’s ‘Vision 2025’ statement. The ATSB’s vision is to ‘stop accidents’, with a mission to ‘drive safety action in a rapidly changing transport environment.’ Vision 2025 is aspirational, sharpening the agency’s focus when conducting investigations, while the mission recognises the transformational nature of the transport operating environment in which investigations are being conducted, and our intention is to influence safety outcomes in that environment.
The vision statement will reflect elements of the Minister’s new Statement of Expectations, issued on 15 July 2019. This includes the need to give priority to transport safety investigations that will deliver the greatest public benefit through improvements to transport safety. Focusing on the public benefit means that the ATSB will have regard for factors that include the potential to save lives, as well as preventing serious adverse economic impacts that result from accidents. There are costs that come with providing safe transport systems, but the cost of an accident can be much higher.
I will also ensure the ATSB pays close attention to the government inquiries related to transport reforms. Two in particular have the potential to result in jurisdictional changes for the ATSB if there are any recommendations resulting in policy change. The Productivity Commission’s inquiry into National Transport Regulatory Reform is looking at the impacts of the rail, marine and road heavy vehicle changes that came out of intergovernmental agreements from 2011 to move the industries towards single national jurisdictions. The Australian Government Review of National Road Safety Governance is examining how to bring down the number of road deaths and serious injuries. Consistent with the Minister’s Statement of Expectations, the ATSB is providing input into these reviews.
I am positive about the agency and the role we will play in improving transport safety going forward. The ATSB has been through significant organisational change over the last few years, all directed towards enhancing our productivity and establishing a shared vision. The ATSB’s staff are dedicated, hard-working experts in their field. Their contribution to safety is highly valued and, with their support, I intend to ensure they are empowered and enabled to make this contribution well into the future.
Weather-related general aviation accidents remain one of the most significant causes for concern in aviation safety; the often-fatal outcomes of these accidents are usually all the more tragic because they are avoidable.
The dangers of visual flight rules (VFR) pilots flying into instrument meteorological conditions (IMC) have been recognised for a very long time, yet VFR pilots still fly into deteriorating weather and IMC. In the decade from 1 July 2009 to 30 June 2019, 101 VFR into IMC occurrences in Australian airspace were reported to the ATSB. Of those, nine were accidents resulting in 21 fatalities. That is, about one in 10 VFR into IMC events result in a fatal outcome.
Flying into IMC can occur in any phase of flight. However, a 2005 ATSB research publication – General Aviation Pilot Behaviours in the Face of Adverse Weather (B2005/0127) – concluded that the chances of a VFR into IMC encounter increased as the flight progressed, with the maximum chance occurring during the final 20 per cent of the flight distance.
This publication describes a selection of weather-related general aviation accidents and incidents that show weather alone is never the only factor affecting pilot decisions that result in inadvertent IMC encounters. These investigations consistently highlight that conducting thorough pre-flight planning is the best defence against flying into deteriorating weather.
The ATSB encourage all pilots, no matter what their experience level, to develop the knowledge and skills required to avoid unintentional operations in IMC. Have alternate plans in case of unexpected changes in weather, and make timely decisions to turn back, divert or hold in an area of good weather. The use of a ‘personal minimums’ checklist can also be a strong mitigator against the risk of flying into bad weather. Checklists can help pilots more clearly identify risk factors.
Flight planning requirements
Prior to a flight, a pilot must study all available information appropriate to the intended operation, including the current weather forecasts. This is even a requirement in the Civil Aviation Regulations (CAR 174) and repeated in the Aeronautical Information Publication.
Apart from the more straightforward and mechanical elements of the flight preparation, such as how much fuel to carry, planning should include anticipating the unusual, and preparing a course of action should it occur.
Pre-flight planning minimises in-flight decision errors because it removes the unforseen element from situations that arise during the flight. Failure to carry out this prior planning can result in decisions being made under a situation of considerable stress and increases the likelihood of poor or incorrect decision making.
In December 2008, a Cessna 172 with a pilot and one passenger departed Mudgee, New South Wales (NSW), on a private VFR flight to a property near Glen Innes, NSW. Although having visually assessed the weather conditions at Mudgee Aerodrome as suitable for departure, the pilot chose not to obtain the relevant aviation weather forecasts for the flight.
About 15 minutes after departure, the weather ahead deteriorated, with increasing cloud above and below the aircraft and the cloud base lowering. With the intention of assessing the weather ahead, the pilot climbed the aircraft to ‘on top’ of the cloud. Observing that the cloud ahead was increasing, with a blanket of cloud below and building thunderstorms, the pilot decided not to stay above the cloud. Rather than choosing to turn back or divert, the pilot descended the aircraft visually through a hole in the cloud, while continuing on toward the intended destination.
When levelling out, the pilot realised the aircraft had descended into a closed valley framed by ridgelines on its eastern, western and northern sides. After flying up the valley for a short time, the pilot decided to turn back.
During the turn-back manoeuvre, the aircraft entered cloud, the pilot became disoriented, and the aircraft collided with terrain. The pilot and passenger were seriously injured in the collision and shortly after, the passenger succumbed to their injuries.
Lessons learnt
One of the key risk controls to avoid becoming a VFR pilot entering IMC is appropriate pre-flight preparation and planning. Pilots should always obtain up-to-date weather information before and during flight. The more doubtful the weather, the more information you will need to get and the more planning is required. Your passengers trust you to make responsible decisions about whether it is safe to fly.
In October 2010, the pilot of a Gippsland Aeronautics GA-8 Airvan, was conducting a charter flight from Lady Barron Aerodrome, Flinders Island, Tasmania. The forecast weather was marginal for flight under VFR, with broken cloud forecast down to 500 ft above mean sea level in the area. However, the pilot’s assessment from the ground was that the cloud base was 1,000 ft to 1,500 ft.
During the climb after take-off, the weather conditions deteriorated to below those necessary for flight under VFR. The pilot, concerned about adhering to an unwritten operator rule to maintain a minimum height of 1,000 ft, continued to climb into IMC instead of remaining visual below the cloud and lost all visual reference with the ground and horizon.
The pilot, who was not qualified to fly in instrument meteorological conditions, continued to fly in IMC for several minutes in the hope of climbing above the cloud. When this did not happen, the pilot decided to turn the aircraft back towards Lady Barron Aerodrome, initiating a gentle turn to the right. The pilot succeeded in maintaining controlled flight with reference to the aircraft’s flight instruments. While intending to turn through 180°, the pilot inadvertently turned less than this and flew towards high ground in the Strzelecki National Park.
Becoming visual, the pilot turned the aircraft into a valley unable to turn around nor out-climb. The pilot elected to conduct a forced landing into the treetops, slowing the aircraft to land at the slowest speed possible. Luckily, only one passenger sustained minor injuries and the pilot and other five passengers were uninjured.
Lessons learnt
If you encounter deteriorating weather, turn back or divert before you are caught in cloud. For a non-instrument rated pilot, even with basic attitude instrument flying proficiency, maintaining control of an aircraft in IMC by reference to the primary flight instruments alone entails a very high workload that can result in narrowing of attention and loss of situational awareness.
At about 5.30 pm on 7 November 2015, the owner-pilot of an Airbus Helicopters (Eurocopter) EC135 departed Breeza, NSW, on a VFR private flight with two passengers on board to Terrey Hills, NSW.
About 40 km to the south-west of the Liddell mine, the pilot diverted towards the coast, probably after encountering adverse weather conditions. Witnesses observed the helicopter overfly the Watagan Creek valley in the direction of higher terrain. The helicopter was then observed to return and land in a cleared area in the valley.
After 40 minutes on the ground, the pilot, who did not hold an instrument rating and was limited to visual flight operations, departed to the east towards rising terrain in marginal weather conditions. About seven minutes later, and approximately 9 km east of the interim landing site, the helicopter collided with terrain. A search was initiated about 36 hours later. The helicopter wreckage was found late on 9 November 2015. The pilot and two passengers were fatally injured.
The ATSB found that the pilot likely encountered reduced visibility conditions leading to loss of visual reference leading to the collision with terrain. The ATSB also found that the fixed, airframe-mounted emergency locator transmitter had been removed and that personal locator beacons which required manual activation were carried instead. While in this accident it did not affect the outcome for the occupants, the lack of activation, combined with the absence of flight notification information, delayed the search and rescue response.
Lessons learnt
Avoiding deteriorating weather or IMC requires thorough pre-flight planning, having alternate plans in case of an unexpected deterioration in the weather, and making timely decisions to turn back or divert. For VFR pilots pressing on into IMC conditions carries a significant risk of encountering reduced visual cues leading to disorientation. This can easily affect any pilot, no matter what their level of experience. In the event of inadvertent entry into IMC, pilots are encouraged to contact air traffic control for assistance.
Spatial disorientation
In order to correctly sense the orientation of the body relative to its environment, a pilot relies on a number of sensory systems in order to establish or maintain orientation:
the visual system
the vestibular system, which obtains its information from the balance organs in the inner ear
the somatic sensory system which uses the nerves in the skin and proprioceptive senses in our muscles and joints to sense gravity and other pressures on the body.
The visual system is by far the most important of the three systems, providing some 80 per cent of the raw orientation information. In conditions where visual cues are poor or absent, such as in poor weather, up to 80 per cent of the normal orientation information is missing. Humans are then forced to rely on the remaining 20 per cent, which is split equally between the vestibular system and the somatic system. Both of these senses are prone to powerful illusions and misinterpretation in the absence of visual references, which can quickly become overpowering.
Pilots can rapidly become spatially disoriented when they cannot see the horizon. The brain receives conflicting or ambiguous information from the sensory systems, resulting in a state of confusion that can rapidly lead to incorrect control inputs and resultant loss of aircraft control.
Simulator experiments at the University of Illinois determined that on average, a pilot with no instrument training can expect to retain control of their aircraft for only 178 seconds after entering bad weather and losing visual contact.
In December 2009, a Bell 206L helicopter was being operated in the area of Dorrigo, NSW, conducting fire observation, water bombing and personnel insertion duties under VFR. The cloud in the area of the helicopter landing and take-off point at around the time of the accident was fluctuating around the minimum required for VFR flight.
During the initial take-off, the experienced pilot recalled raising the helicopter into a low hover and conducted a pedal turn through 360° to get a better look at the weather and establish an appropriate departure direction. The pilot said that the weather looked better in the low hover than it did on the ground, so elected to climb to about 100 ft into a high hover.
The pilot reported looking inside the cockpit for a couple of seconds to survey the instruments. When returning focus outside, the pilot lost visual reference and became spatially disoriented, rapidly leading to incorrect control inputs and loss of control. The helicopter impacted the ground in an uncontrolled state. The passenger was fatally injured, and the pilot was seriously injured.
Lessons learnt
Even momentary loss of outside visual reference can result in spatial disorientation, incorrect control inputs, and loss of control. Whenever the natural horizon is not clear enough to control the aircraft by visual reference, such as often occurs in marginal VMC, all pilots, no matter what their flight experience level, are potential victims of spatial disorientation.
In November 2007, the pilot of a Cessna 337 Skymaster was conducting a private VFR flight from Moorabbin Airport, Victoria, to Merimbula, NSW. The pilot, who was only qualified to operate in VMC, had indicated the flight would track along the coast at low level.
The forecast weather included isolated showers or thunderstorms over the sea and coast, and low cloud over the sea/exposed coast. The low cloud was expected to be broken stratus between 800 ft and 2,000 ft. Visibility was quoted as reducing to 3 km in thunderstorms with rain and 6 km in showers of rain.
About 30 minutes after departing Moorabbin, people on a beach south-east of Venus Bay heard and then suddenly saw the aircraft emerge from fog at low level, flying above the water line on the beach with the wings level. Within seconds, the Skymaster turned right at a steep angle of bank while maintaining height and headed out to sea before disappearing from sight into the fog. Witnesses reported no apparent problem with the engines and the aircraft appeared to be under control. About two seconds after the aircraft disappeared from view, they heard a ‘bang’ and then silence.
Two days later, wreckage of the aircraft and three of the deceased occupants were found washed up on the beach. The pilot was not found.
The investigation concluded that while manoeuvring over water at low level in conditions of reduced visibility, the pilot probably became spatially disorientated and inadvertently descended into the water.
By turning away from the land in the foggy conditions, the pilot would have encountered a featureless, grey environment with no visible horizon, making it extremely difficult to judge the aircraft’s attitude and/or height.
Lessons learnt
As a pilot you should accept that flying under VFR will not always enable you to reach your planned destination. Weather often does not act as the forecast predicts. You must have alternatives available, and you must be prepared to use them—even if it means returning to your departure point.
In forecast marginal weather, careful pre-flight planning is essential and must include a thorough analysis of the latest weather forecasts and consideration of your available options. Those options should be evaluated while en route to ensure you have an alternative course of action available which provides for a safe landing.
Personal limitations
When deciding on whether it is safe to fly, pilots should consider not only the route to be flown, the prevailing weather and aircraft serviceability, but their own physical and emotional fitness and flying experience. In other words, to be a competent pilot, you must know and fly within your own limitations.
Adhering to a pre-flight ‘personal minimums’ checklist will go a long way toward keeping you safe. For example, the decision to turn back or divert will be easier if you have decided in advance what your personal minimum VFR flying altitude will be. That minimum altitude may well be much more conservative than the legal requirement.
In September 2008, a Cessna 206 departed Bankstown, NSW, on a private flight to Archerfield, Queensland, via Scone, NSW. The private pilot had purchased the aircraft on the morning of the accident flight and was advised that the flight should track along the coast to Archerfield to avoid any weather problems. However, the pilot indicated an intent to visit friends in Scone.
The aircraft landed at Scone Airport and was met by friends of the pilot, who observed the subsequent take-off, in what was described by another pilot as ‘poor weather’. The aircraft was reported missing when it did not arrive at its planned destination. The following day, the wreckage of the aircraft was located on top of a ridge in rugged terrain, approximately 56 km north-north-east of Scone Airport. The pilot and his two passengers were fatally injured.
The investigation concluded that the pilot was probably attempting to return to Scone after encountering weather unsuitable for flight under VFR, and that the circumstances of the accident were consistent with controlled flight into terrain after encountering IMC.
It was determined that both the forecast and actual weather conditions were not suitable for VFR flight on the planned route, with low cloud, rain showers and high winds. The pilot most probably did not check the forecast weather before the flight. The route chosen for the flight was not suitable for the aircraft in the prevailing weather conditions.
Lessons learnt
Although the pilot would have been generally aware of the weather situation from observations during the flight from Bankstown, and at Scone itself, without knowledge of the forecast weather on the route selected it is unlikely that adequate consideration was given to the risks inherent in continuing the flight.
Attempting continued VFR flight when the weather clearly does not support it compromises the safety of yourself and your passengers. Running out of altitude and/or visibility leaves you without alternatives.
In June 2007, a Cessna Caravan float plane departed Broome Airport, Western Australia (WA), on a VFR charter flight to Talbot Bay, WA. On board the aircraft were the pilot and 10 passengers.
About 40 minutes into the flight, the weather conditions deteriorated and the pilot elected to return to Broome. During the return, the aircraft entered an area of reduced in-flight visibility that resulted in the loss of the visual horizon and, while manoeuvring the aircraft to regain VMC, the pilot became disoriented.
The non-instrument-rated pilot made a general radio broadcast requesting assistance, which was received by the crew of another aircraft who initially advised the pilot of the Caravan to concentrate on maintaining the aircraft’s orientation using its attitude indicator. After confirming that the Caravan pilot was maintaining the aircraft’s attitude with reference to its instruments, the assisting pilot advised to set cruise power, and to maintain level flight with reference to the vertical speed indicator.
The crew of the assisting aircraft reported that, about five minutes after the initial radio contact, the pilot of the Caravan sounded less stressed and advised the aircraft was in level flight. The flight continued on to Broome, which required the pilot to descend through cloud before becoming visual and landing safely.
Lessons learnt
The potentially severe consequences of this occurrence were probably avoided by the pilot’s decision to seek assistance and the ability of the flight crew of the other aircraft to provide appropriate input and guidance. If you find yourself in marginal weather and becoming disoriented or lost, seek whatever help is available. Air traffic control can provide assistance, especially if you are in radar coverage.
Having entered deteriorating weather, many pilots will descend to remain in VMC. Apart from the terrain hazards, descending may eliminate radar and communication contact. In order to get the aircraft safely on the ground it is up to the pilot to keep the aircraft under control. Being able to make a 180° turn, and if necessary climb to a safe altitude, requires proficiency at basic flying manoeuvres on instruments. Those skills, learned while training for the Private Pilot Licence, disappear if not regularly practised.
On 16 June 2017, a Cessna 172 was being operated on a private flight from Southport Mason Field, Queensland, to Ballina Airport, NSW. The purpose of the flight was to ferry the aircraft to Ballina for scheduled maintenance before the expiry of the aircraft’s maintenance release on 17 June 2017.
En route, near the town of Bangalow NSW, the aircraft entered an area of reduced visibility, including low cloud, fog and drizzle. The aircraft diverted off the initial track and was last seen disappearing into cloud heading inland. A short time later the aircraft collided with terrain and the pilot was fatally injured.
The ATSB found that the decision to depart on the flight had placed the pilot at risk of encountering conditions of reduced visibility. On entering those conditions, the pilot likely became spatially disoriented, resulting in a loss of control and a collision with terrain. The investigation also found that the pilot was likely under some degree of self-imposed pressure to meet a pre-arranged appointment, despite the inclement weather conditions.
Lessons learnt
VFR pilots should use a ‘personal minimums’ checklist to help control and manage flight risks by identifying risk factors that include marginal weather conditions and only fly in environments that do not exceed their capabilities.
A personal minimums checklist is an individual pilot’s own set of rules and criteria for deciding if and under what conditions to fly or to continue flying based on your knowledge, skills and experience. As a personal ‘go/no go’ checklist they can help take the stress out of difficult decisions both before and during flight, acting as a safety buffer between the demands of the situation and the extent of a pilot’s skill.
Conclusion
Pilot decision making, particularly weather-related decision making, is complex and there is no single solution to the problem of VFR into IMC occurrences. However, there are a number of measures which can be used to reduce the significant risk inherent in the operation of VFR into IMC.
The ATSB’s report Improving the odds: Trends in fatal and non-fatal accidents in private flying operations, found that problems with pilots’ assessing and planning were contributing factors in about half of all fatal accidents in private operations.
The report encourages all pilots to consider the following strategies:
make decisions before the flight
continually assess the flight conditions (particularly weather conditions)
evaluate the effectiveness of their plans
set personal minimums
assess your fitness to fly
set passenger expectations by making safety the primary goal
seek local knowledge of the route and destination as part of their
pre-flight planning.
Also, becoming familiar with the aircraft’s systems, controls and limitations may alleviate poor aircraft handling during non-normal flight conditions. Finally, pilots need to be vigilant about following rules and regulations that are in place—they are there to prevent errors being made before and during flight. Violating these regulations only removes these ‘safety buffers’.
Flight Planning Kit — always thinking ahead. A flight planning guide designed to help you in planning and conducting your flight. Includes a handbook outlining eight stages of a flight; flight planning notepad; personal minimums checklist; time in your tanks card and more.
Weather to Fly DVD — highlights the dangers of flying in cloud, and how to avoid VFR into IMC.
Look out! Situational Awareness — an informative DVD on situational awareness and why it is vital to flying safety.
Safety Behaviours: Human factors for pilots (second edition) resource kit — includes a series of booklets and videos on a wide range of topics such as situational awareness, decision-making, and threat and error management. Also available online at www.casa.gov.au/hf(Opens in a new tab/window)
CASA holds free seminars for pilots held across Australia. VFR operations into IMC, situational awareness and decision making are just some of the safety issues covered. Find out more at www.casa.gov.au/avsafety(Opens in a new tab/window)
Flight Safety Australia, CASA’s flagship aviation safety magazine and website, is topical, technical, but reader-friendly, with articles covering all the key aviation safety issues. Flight Safety Australia has produced a number of articles that focus on VFR into IMC, and spatial awareness, including:
As the accountable authority for the Australian Transport Safety Bureau (ATSB), I am pleased to present the ATSB’s 2018–19 Corporate Plan, which covers the period 2018–19 to 2021–22.
This Corporate Plan sets out the ATSB’s purpose – to improve transport safety – and its strategies for achieving that purpose. The Plan also sets out the ATSB’s key deliverables and associated performance criteria. It has been prepared consistent with paragraph 35(1)(b) of the Public Governance, Performance and Accountability Act 2013 and the relevant provisions of the Transport Safety Investigation Act 2003 (the TSI Act), which establishes the ATSB. It also incorporates the Minister for Infrastructure and Transport’s Statement of Expectations (SOE) as notified under Section 12AE of the TSI Act.
The TSI Act provides that the ATSB’s primary purpose is to improve the safety of aviation, rail and marine transport through accident investigation, data analysis and safety education. It must do so independently while cooperating with the other organisations that share responsibility for transport safety, including counterpart organisations in other countries. Successive governments have indicated that, in carrying out its role, the ATSB should give priority to the safety of the travelling public.
To accomplish its primary purpose, the ATSB must take into account the known and projected environmental challenges associated with continuing growth, emerging technologies and safety trends across the aviation, rail and marine transport sectors. In response, the ATSB is preparing a Vision Statement 2025 that will provide a roadmap for the ATSB into the future, driving safety action in a rapidly changing transport environment. I will release the Vision Statement during the current year.
In my capacity as Chief Commissioner and Chief Executive Officer, I am fully committed to maintaining the ATSB’s reputation as a world leading safety investigation body. Consistent with this commitment, I will work collaboratively with the relevant authorities to ensure the ATSB is appropriately resourced to fulfil its legislative duties and positioned to meet the expectations of our stakeholders and the broader travelling public.
The air traffic control safety net fails when human errors go undetected and uncorrected. These operational errors are generally more likely to occur in circumstances such as very high or very low workload situations, or events involving complex coordination. Predisposing or underlying factors relating to the ATC operational environment can influence the frequency, and the consequences, of operational errors. System safety can be improved by the identification and rectification of these predisposing factors.
Information from air traffic controllers from each sector within the Brisbane AACC. together with the results of interviews with the management from the Northern District and Central Office Air Traffic Services Division formed the basis of this investigation.
The investigation identified a number of local factors associated with the task and the environment which may increase the probability of errors by individual controllers. Task related issues included the operation of VFR aircraft in the Brisbane Terminal Area, and the relationship between the AACC and Brisbane and Archerfield Control Towers. Also highlighted within the AACC was what is referred to in the report as the 'service ethos', or the tendency for air traffic controllers to provide an. individualised service to aircraft at the expense of a regularised traffic flow. The level of awareness of human performance capabilities and limitations among the controllers interviewed was found to be minimal.
At the time of the investigation, training was under way for the implementation of teams and for transition to ICAO airspace (which was deferred shortly after interviews with the controllers were completed). This placed a considerable training burden on the AACC and there was a strong view among the controllers that too many changes were being introduced into the ATS system in too short a time frame. In addition, it was apparent that the management view of what the changes involved differed markedly from the understanding held by the controllers. It seemed that the human factors aspects of the change process (i.e. those involving the controllers) were not addressed by management to the same extent as were the "mechanical" aspects such as procedural and technical changes. Consequently, the recommendation is made that ATS Division devotes more attention and resources to the processes and mediums by which it leads its workface employees through the change cycle.
The effective two-way flow of information within a system is an important determinant of the "safety health" of that system. The introduction of teams at the Brisbane AACC in early October 1993 was a major step in facilitating improved information flow to and from the workface. Nevertheless, at the middle management level, significant deficiencies were identified in the communication network. These were the geographic separation of the office of the Manager AACC from the AACC itself, and a similar separation between the third and some of the fourth level management officers. This latter aspect will largely be overcome in April 1994 when the city office relocates to the airport. However, a Jack of suitable building space has prevented the Manager AACC from being co-located with the AACC and there are currently no plans for such a move. The investigation concludes that this aspect should be reassessed as a matter of urgency.
Communication was also identified as an issue at the corporate level. Liaison between the various managerial levels seemed to work effectively with regard to local and national initiatives formulated in Central Office. However, feedback to the workface concerning projects in which controllers were involved usually occurred at the conclusion of a project. This may result in controllers feeling they have little commitment to development, despite the involvement of district office representation.
Commitment of the workforce is a prerequisite to successful change. Evidence seems to indicate that in some respects this has been lacking despite the resources committed by management to the orientation of controllers. Change in the Australian ATS environment is inevitable and ATS Division therefore needs to re-examine the processes and mediums through which it educates its employees with particular reference to the implementation process for TAAATS.
