The ATSB has released its investigation report into the 18 November 2009 ditching of an Israel Aircraft Industries Westwind 1124A that occurred off Norfolk Island. The report found that the need to ditch the aircraft arose from incomplete pre-flight and en route planning and the failure to assess that a safe landing could not be assured before it was too late to divert. The investigation also confirmed the benefit of clear in-flight weather decision making guidance and its timely application by pilots in command.

The flight was an aeromedical retrieval from Apia, Samoa bound for Melbourne via Norfolk Island. It was carrying a pilot in command (PIC), copilot, a doctor, a nurse, a patient and one passenger. The pilot submitted a flight plan to leave Apia bound for Norfolk Island, a journey of four and a half hours.

The PIC received the latest aerodrome forecast (TAF) for Norfolk Island from the briefing officer while submitting the flight plan. The forecast was valid beyond the period of the flight and indicated that the weather conditions would be suitable for landing. Based on that forecast, there was no requirement to plan or to carry fuel for the possibility of a diversion to an alternate airport.

Various weather reports and forecasts, both routine and special, were available en route through air traffic control. Special weather reports (or SPECIs) are issued when there is significant deterioration or improvement in airport weather conditions. The flight crew did not realise the significance of the changed conditions reported in a SPECI for Norfolk Island until after they had committed to landing on Norfolk Island. By this time they had insufficient fuel reserves to divert to another destination.

The crew attempted a night approach and landing on Norfolk Island, but the weather conditions prevented them from seeing the runway or its visual aids, and therefore, from landing. After four failed attempts, the PIC elected to ditch the aircraft in the sea 3km south-west of Headstone Point on Norfolk Island, before its fuel was exhausted. The aircraft broke in two after ditching. All the occupants escaped from the aircraft and were rescued by boat, although two sustained serious injuries. 

The report found that the operator's procedures and flight planning guidance managed risks consistent with regulatory provisions but did not minimise the risks associated with aero-medical operations to remote islands. Clearer guidance on the in-flight management of previously unforecast, but deteriorating destination weather might have assisted the crew to consider and plan their diversion options earlier.

As a result of this accident, the operator changed its guidance for the management of previously unforecast deteriorating destination weather. Satellite communication has been provided to crews to allow more reliable remote communications and its flight crew oversight systems and procedures have been enhanced. CASA is also developing a number of Civil Aviation Safety Regulations covering fuel planning and in-flight management, the selection of alternate destinations and extended diversion time operations.

Read the final report: Fuel planning event, weather-related event and ditching involving Israel Aircraft Industries Westwind 1124A, VH‑NGA, 6.4 km west-south-west of Norfolk Island Airport, on 18 November 2009

The ATSB's investigation into the loss of the main rotor drive on a Robinson R44 Raven II (AO-2011-088) helicopter found that it was associated with corrosion and subsequent fatigue failure of the main rotor gearbox gear carrier as a result of water present in the main rotor gearbox.

The helicopter, registered VH-ZWC, had departed Darwin Airport bound for Bamurru Plains in the Northern Territory on 28 July 2011. About 30 minutes into the flight the aircraft lost its main rotor drive and the pilot conducted an autorotative descent and landing. There were no reported injuries.

The helicopter manufacturer advised that there had been a similar instance of corrosion-related gearbox failure in an R44 helicopter. In each case the aircraft had been operated in similar climatic conditions in Australia's tropical north and had been stored outside, not in hangars.

The helicopter manufacturer has now modified the design of the gear carrier to incorporate a metallic cadmium surface plating to improve the corrosion resistance of the assembly.

In May 2012 the Civil Aviation Safety Authority (CASA) released Airworthiness Bulletin 63-008, to raise awareness of the hazards associated with R44 gearbox internal corrosion due to water ingress.

The CASA bulletin made several recommendations to reduce the risks to those carrying the original assemblies, including:

• that operators and maintainers requesting their maintenance facility conduct a MRGB oil inspection for any contaminants such as water, rust or paint
• where appropriate store the rotorcraft under cover, or cover the main rotor mast and head assembly during inclement weather conditions
• during lengthy periods of storage or inactivity in tropical conditions take additional preservation action (seek advice from Robinson Helicopter Company)
• in the event of a MRGB warning chip light indication, land the helicopter immediately and have the issue investigated by a LAME in accordance with the manufacturer's instructions
• report all water, rust and paint contamination of the MRGB oil system and any corrosion to CASA.

Read the final report: Loss of main rotor drive Robinson Helicopter R44, VH-ZWC, 83 km east of Darwin Airport, Northern Territory, on 28 July 2011

Read CASA's Airworthiness Bulletin 63-008 (Opens in a new tab/window)

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