The hazards of flying visually in poor weather have again been highlighted following the ATSB’s investigation (AO-2011-085) into the fatal accident of a Bell 206L helicopter near South Turramurra, NSW.

On 22 July 2011 the helicopter, with a pilot and one passenger, departed from Rosehill, NSW on a private flight to the Sydney Adventist Hospital near South Turramurra.

As the aircraft neared its destination the pilot encountered low cloud and rain. Shortly after, witnesses saw the helicopter descending rapidly with the tail section separated. The helicopter collided with the terrain, fatally injuring both occupants. The investigation found it was likely that during manoeuvring in the area of low cloud and rain the pilot inadvertently flew into reduced visibility conditions. This led to the onset of disorientation and loss of control of the helicopter.

Accidents of this kind are still far too common and doubly tragic because most are avoidable. In the five years 2006-10 there were 72 instances of visual flight rules (VFR) pilots flying in instrument meteorological conditions (IMC) reported to the ATSB. Seven of these resulted in accidents and caused 14 fatalities. Statistically, about one in ten VFR into IMC events results in a fatal outcome.

A recently released ATSB avoidable accident booklet highlights the risks of flying visually into poor conditions.

The booklet offers some important key messages to pilots:

• It is essential to do your pre-flight planning and have alternative plans in case of an unexpected deterioration in the weather.
• Make timely decisions to turn back or divert.
• The risks of spatial disorientation are heightened when pressing on into IMC conditions.
• Use 'personal minimums' checklists to help control and manage flight risks by identifying risk factors including marginal weather conditions.
• Set passenger expectations by making safety the primary goal.

Read the final report: VFR into IMC - South Turramurra, New South Wales, on 22 July 2011, VH-CIV, Bell 206L Helicopter

The ATSB is urging rail workers to keep safe when working on track.

The ATSB's advice follows our investigations into accidents involving unsafe work practices, particularly surrounding communications and track occupancy.

In May 2010 a collision between an XPT passenger train and a track-mounted excavator near Newbridge, NSW resulted in the death of the excavator operator. In another incident near Jaurdi, WA in March 2011, a freight train collided with a track mounted excavator-the train driver sustained a minor injury and there was significant damage to the track.

In the Newbridge incident the workers were operating under Track Occupancy Authorities (TOA) and had been authorised to occupy and work on the tracks. Neither the Protection Officer (PO) nor the Network Control Officer (NCO) had positively identified the location and type of worksite. Their actions were influenced by a deficiency in the TOA form, in that no provision was provided to record this critical information. Both the PO and the NCO had wrongly assumed that the train had already passed beyond the limits of the worksite. The problem was compounded when the workers accessed the danger zone before the PO had put in place the normal site protection measures such as detonators and flags. 

As a result, the Australian Rail Track Corporation (ARTC) reinforced the rules and procedures for the issuing of TOAs. The ARTC also implemented a revised TOA form that records critical information about the location and type of worksite.

The investigation into the collision near Jaurdi found that two track mounted excavators had been placed back on the track without permission of the Authorised Employee responsible for the coordination of track side safeworking activities at the site. Other findings were that the communication equipment available to the track crews was inadequate, the sharing of safeworking protection information at pre-work briefings had not occurred and the application of a WestNet Rule had been simplified.

Communication, information and safe work practices play a critical role in keeping our tracks safe.

• RO-2010-004 - Collision between XPT passenger train WT27 and a track-mounted excavator, near Newbridge, New South Wales, on 5 May 2010
• RO-2011-006 - Collision between freight train 7SP3 and a track mounted excavator, near Jaurdi, Western Australia, on 28 March 2011

The ATSB is reminding rail operators of the risks surrounding unsecured loads.

An ATSB investigation into the April 2012 derailment of a ballast train near Broken Hill, NSW shows how uneven loading of wagons can lead to instability, with the potential for serious incidents or accidents.

The train comprised two locomotives hauling 34 ballast wagons and one ballast plough car at the rear for the purpose of distributing ballast along a re-sleepered track. Ballast is the coarse stone used to form the bed of the railway track. The ballast wagons were AHBY class ballast hopper type with discharge doors in the middle of the wagon.  

The day before the incident, a front end loader loaded ballast into the wagons from a ramp constructed from ballast adjacent to the track. The filling procedure was to place a bucket load at each end of the wagon with crew visually checking every bucket load to ensure there was no discharge under the wagon. The train was then stabled for the night. When preparing the train for departure the next morning the crew noticed that the middle door on one of the wagons was open and a small amount of ballast had discharged from it. Because the discharge seemed small, they assumed the wagon was still full and that the load would have remained stable.

Shortly after the train's departure, the crew noticed 'dust and sparks' coming from the rear of the train. After stopping and inspecting the train, the crew discovered that the 26th wagon had derailed both bogies (wheeled undercarriages). Four kilometres of track was also considerably damaged.

The ATSB investigation showed that the discharge door of the wagon had been left open and had discharged a large amount of material during shunting operations before the train set off. As a result, the load had become seriously uneven. The wagon then derailed on a curve. Similar incidents have been reported of trains carrying coal and other bulky cargoes.

To ensure wagons are evenly loaded, rail operators should ensure they follow and carry out their load distribution checking procedures to the required standard.

Read the final report: Derailment of Ballast Train 8M24N, near Broken Hill, New South Wales, on 11 April 2012

The Australian Transport Safety Bureau is supporting Rail Safety Week, which is being held from 13-19 August 2012.  In its seventh year, Rail Safety Week is an initiative of the Australasian Rail Industry and aims to raise awareness in the community of safety issues around railway lines.

During Rail Safety Week operators come together to promote safety around rail tracks and level crossings. As part of the week, the ATSB will share key safety messages with the rail community. These messages come from the findings we've uncovered from our rail investigations.

Check out the Rail Safety Week website for more information. 

The ATSB's investigation AO-2011-151 into an incident on 8 October 2011 has once again highlighted the risks of pilots becoming distracted during the critical stages of flight preparation. It also emphasises the importance of good flight crew communication to ensure a shared understanding of an aircraft's systems status.

The incident occurred when the flight crew of an Airbus A380-800, registered VH-OQE, was preparing for departure from Los Angeles International Airport. Before take-off, the captain changed the departure runway that was entered in the aircraft's flight management system. The procedure for completing that task was not followed exactly, resulting in the take-off speeds not being displayed on the flight instruments.

During the take-off roll, the flight crew, becoming aware that the take-off speeds were not displayed, called out the speeds from their notes instead, and proceeded with the take-off. At all times during the take-off, the crew were aware of how fast they were going. However, the take-off speeds that are normally displayed on the airspeed indicator were not visible for this take-off.

The ATSB found that the captain had been distracted from updating the runway change in the aircraft's navigation systems before the aircraft taxied for the runway. Twice, before take-off, the aircraft's systems displayed a message to check take-off data. The first officer cleared the first message on the understanding that the take-off data would be checked and in the second instance, believing that it had been checked. There were no other warnings to alert the crew that they were commencing the take-off without the take-off speeds in the aircraft's navigation systems.

Following this incident the aircraft manufacturer has updated the aircraft's warning systems as part of a planned upgrade program. This upgrade will issue a warning if take-off is commenced without the take-off speeds having been entered into the aircraft's systems. Qantas advised that their standard operating procedures have been updated to avoid any misinterpretation of the required actions in the case of a runway change.

Read the final report: Operational event - Airbus A380, VH-OQE, Los Angeles International Airport, United States, on 8 October 2011

By notifying the ATSB of aviation accidents and incidents you could make a real difference to the safety of your fellow aircrew.

As the national transport safety investigator, the ATSB is the Australian Government agency you should notify in the event of an aviation accident or incident.

While we use your notification to determine whether to investigate an occurrence, looked at as a whole, notifications also give us a bigger picture of aviation safety trends and patterns.

Like a jigsaw piece in a bigger puzzle, certain notifications can often be joined together to reveal a broader, systemic safety problem. Once we've identified an accident or incident trend from your notifications, we can make tangible improvements to safety through safety advisory notices, recommendations and further safety investigations.

Besides the obvious safety benefits of reporting an occurrence, there are also legal requirements to report certain accidents and incidents to the ATSB. Even if there are no injuries or there is minimal aircraft damage, you must still let the ATSB know. Remember that the ATSB does not investigate to lay blame or apportion liability - we investigate to improve safety and prevent an accident from happening again.

You can report an accident or serious incident (an Immediately Reportable Matter - IRM) to the ATSB 24 hours a day, seven days a week:

• call 1800 011 034 (you can also use this number if you need advice or clarification on reporting matters)
• submit a written report - Submit a Mandatory Notification

The ATSB has produced a series of posters to remind pilots, aircrew and operators to report an accident or serious incident to the ATSB. The posters are available free of charge by calling 1800 020 616 or emailing atsbinfo@atsb.gov.au

A new Bill passed by Parliament will see the ATSB take responsibility for investigating safety events on the critical metropolitan passenger and freight rail networks across Australia.

A new era for rail safety investigation

From 1 January 2013, Australia's national transport safety investigator, the Australian Transport Safety Bureau (ATSB), will take responsibility for investigating safety events on the critical metropolitan passenger and freight rail networks across Australia.

This national focus will see more investigations conducted across a greater range of safety matters. Ultimately, it will mean improved safety through the sharing and implementation of safety findings across all states and territories.

A new Bill recently passed by Parliament allows states and territories to request the ATSB to conduct a rail investigation in their jurisdiction. However, as an established rail, aviation and maritime safety investigator, the ATSB will continue to make its own decisions about what to investigate.

The ATSB's national rail safety investigation role will complement the regulatory function of the new national rail safety regulator.

This reform will greatly improve productivity through consistent regulatory and investigation practices between the states and territories.

• National safety Investigation Reforms
• Transport Safety Investigation Amendment Bill 2012(Opens in a new tab/window)

The ATSB is inviting comments on proposed regulatory changes covering mandatory reporting and confidential reporting for rail and aviation, confidential reporting of maritime safety concerns and ATSB use of International Maritime Organisation's Casualty Investigation Code.

Aviation - New mandatory and confidential reporting regulations
Comments are invited on regulatory changes covering mandatory reporting of accidents and incidents and confidential reporting of safety concerns in Australia. The proposed changes advance a previous round of consultation conducted in 2011.

Rail - New mandatory and confidential reporting regulations
Comments are invited on the regulatory changes covering mandatory reporting of accidents and incidents and confidential reporting (REPCON) of safety concerns in Australia. The proposed changes advance a previous round of consultation conducted in 2011.

Marine - New confidential reporting regulations and the International Casualty Investigation Code
Comments are invited on two proposed regulatory changes relating to:

• confidential reporting of maritime safety concerns
• ATSB use of the International Maritime Organization's Casualty Investigation Code

Australia celebrates three decades of independent transport safety investigations.

On 7 June 1982, the Bureau of Air Safety Investigation (BASI) was created as an operationally independent agency, marking the start of a new era in transport safety for Australia.

Now operating as the Australian Transport Safety Bureau (ATSB), Australia's national transport safety investigator has earned its reputation for excellence, both at home and abroad.

More than 4,000 investigations later, the ATSB has become a world-leader in transport safety investigations. It is internationally acknowledged for its excellence as a transport safety investigator based on its reputation in the field of human factors, operational independence, objectivity, and technical expertise.

Whether investigating aviation, marine or rail incidents and accidents, the ATSB is committed to safer transport for industry and the travelling public.

•  More information about the history of transport safety investigations in Australia

The use of mobile phones and other electronic devices is restricted as they could interfere with vital aircraft navigation systems. Current regulations give aircraft crew the power to prohibit the use of any device which can threaten the safety of an aircraft. It is very important that passengers listen to and comply with announcements from the cabin crew when these restrictions apply.

The ATSB recently received a confidential report from an airline passenger concerned that passengers were using their 3G mobile devices onboard a flight from Sydney to Melbourne. The report below outlines the passenger's concerns along with the ATSB's response and advice to the travelling public.

Report narrative:
The reporter expressed a safety concern about the use of 3G mobile devices onboard a Syd-Melb flight. The reporter, who is a regular traveller, observes that passengers are using these devices more and more frequently, texting and using internet connectivity during flight. The reporter believes that cabin crew do not take this safety matter seriously and often do not adequately warn passengers to turn off electronic devices or that the devices should be in flight mode.

Responses/received:
REPCON supplied the operator with the de-identified report. The following is a version of their response:

Cabin safety has advised that a review of our occurrence database from 01/01/11 shows that on over 500 occasions cabin crew have reported the hazard of passengers using their mobile phones and personal electronic devices (PEDs) onboard. It is felt that the sheer volume of reports received in relation to passenger non-compliance with our PED policy illustrates that cabin crew are very aware of the regulatory requirements and company policies on this matter and are very vigilant in ensuring compliance, particularly during the pre-departure preparations as the cabin is being secured for take-off.

In addition, it's quite possible that onboard passengers writing text messages are constructing them whilst their phones are in flight mode. It is also not possible for cabin crew to manage passenger use of PEDs during takeoff and/or the descent phase as the cabin crew must be seated. The reports we receive also highlight passenger reluctance and attitudes towards PED usage and the belief it is the operator's policy and not a regulatory requirement. However, the operator honestly believes the hundreds of reports that come through each year show that our cabin crew take passenger use of PEDs at inappropriate times very seriously.

In addition, the PED policy is currently part of the cabin crew recurrent emergency procedures curriculum and is covered in the "Standard Operating Procedures" section of the training day. The proliferation of PEDs has made the potential much higher for non-compliance but it is not possible for cabin crew to check that all PEDs are switched to flight mode and then off. In this respect cabin crew act in good faith that passengers are compliant, responsible and accountable themselves.

REPCON supplied CASA with the deidentified report and a version of the operator's response. The following is a version of the response that CASA provided:

CASA has reviewed this matter with internal subject matter experts and has examined the operator's procedures, CASA is satisfied with the operator's response.

ATSB comment:
The use of mobile phones and other electronic devices is restricted as they could interfere with vital aircraft navigation systems. Current regulations give aircraft crew the power to prohibit the use of any device which can threaten the safety of an aircraft. It is very important that passengers listen to and comply with announcements from the cabin crew when these restrictions apply.

_________________________

Australia's voluntary confidential aviation reporting scheme

REPCON allows any person who has an aviation safety concern to report it to the ATSB confidentially. All personal information regarding any individual (either the reporter or any person referred to in the report) remains strictly confidential, unless permission is given by the subject of the information.

The goals of the scheme are to increase awareness of safety issues and to encourage safety action by those best placed to respond to safety concerns.

REPCON would like to hear from you if you have experienced a 'close call' and think others may benefit from the lessons you have learnt. These reports can serve as a powerful reminder that, despite the best of intentions, well-trained people are still capable of making mistakes. The stories arising from these reports may serve to reinforce the message that we must remain vigilant to ensure the ongoing safety of ourselves and others.

What may be reported with REPCON?
Any matter may be reported if it endangers, or could endanger the safety of an aircraft. These matters are reportable safety concerns.

Examples include:
• unsafe scheduling or rostering of crew; or
• crew or aircraft operator bypassing safety procedures because of commercial pressures; or
• non-compliance with rules or procedures.

To avoid doubt, the following matters are not reportable safety concerns and are not guaranteed confidentiality:
• matters showing a serious and imminent threat to a person's health or life
• terrorist acts
• industrial relations matters
• conduct that may constitute a serious crime.

Submission of a report known by the reporter to be false or misleading is an offence under section 137.1 of the Criminal Code.

How can I report to REPCON?
Online: www.atsb.gov.au/voluntary.aspx
Telephone: 1800 020 505
Email: repcon@atsb.gov.au
Mail: Freepost 600
PO Box 600
Civic Square ACT 2608