ATSB

Airplane accident on Bathurst Island, Northern Territory

The ATSB is investigating the 5 February accident involving a Cessna 310R on Bathurst Island in the Northern Territory. The aircraft collided with terrain shortly after taking off from Bathurst Island Aerodrome. Last updated 3.05pm - 8 February 2011

Update 3.05pm - 8 February 2011

The ATSB investigation team commenced investigation of the Bathurst Island accident site on Monday morning. Access to the site has been difficult, with dense undergrowth and very wet conditions hampering activities. The investigation team has mapped the wreckage distribution and is proceeding to examine key aircraft systems and structures in closer detail.

Ongoing activities will include interviews with witnesses and aircraft operational and maintenance personnel. Maintenance, training and operation records have been quarantined and will be reviewed as part of the ongoing investigative process.

Update 1.10pm - 7 February 2011

The ATSB deployed a team of four investigators to the accident site on Sunday morning - two officers from the ATSB Canberra central office and two from the Brisbane office. The team arrived in Darwin early Sunday afternoon and commenced investigations by contacting police, Air Services Australia and the aircraft operator. The team will be travelling to Bathurst Island early Monday morning to commence the on-site phase of the investigation.

A preliminary report, containing a summary of factual information gathered during the ATSB's initial investigation, will be issued within 30 days.

More information on the investigation is available on the investigation page AO-2010-017

Helicopter accident in Cessnock NSW

Update 12.10pm - 7 February 2011

The ATSB team of investigators completed their on-site examination of the wreckage on Sunday, 6 February. They have retained several components of the Robinson R44 helicopter, which will be brought back to the Canberra laboratories for examination and analysis.

Today, the investigators will continue to collect other documentation in Newcastle, including training and maintenance records. They will also be interviewing witnesses and other relevant parties.

Further updates will be posted as information comes to hand.

Update 3.10pm - 5 February 2011

The ATSB is investigating an accident involving a Robinson R44 helicopter, registered VH-HFH. The helicopter crashed into the ground at Cessnock Airport in New South Wales and burnt as a result. Of the three occupants, two were fatally injured and one sustained serious injuries.

The ATSB has dispatched a team of four investigators to the site. They will arrive tonight and be on-site for a number of days. During that time, the team will:

examine the site
interview witnesses and the surviving crew member
collect training, maintenance and relevant operator records and documentation.

More information on the investigation is available on the investigation page AO-2011-016

Further updates will be posted as information comes to hand.

Consultation on amendments to Transport Safety Investigations Regulations 2003

Consultation period closes 31 January 2011: The ATSB consultation period for amendments to mandatory aviation accident and incident reporting under the Transport Safety Investigations Regulations 2003 closes shortly. Visit the ATSB website for more information. Updated 2.00pm - 20 January 2010

The Australian Transport Safety Bureau wants your help

We are looking to amend the mandatory aviation accident and incident reporting scheme, and we're keen to hear what you think. The main focus of our proposed changes is revising the detailed list of the reportable matters to provide clarity to those people with reporting responsibilities. This is in the interests of sourcing accident and incident information from the industry that is more targeted for the purposes of use in safety research and analysis and assisting the ATSB to decide which matters to investigate.

In short, we want to ensure that it's easier to make the right notifications, and that the notifications can be of the most use.

Notifications of aircraft accidents and incidents are vital to the Australian Transport Safety Bureau. Not only do they alert us to potential investigations, they also create a vivid and useful portrait of aviation safety in Australia. Investigators and researchers use it to identify patterns and trends, and the ATSB receives many requests each year from the media and researchers (both private and professional) for details and figures of accidents and incidents.

Of the 15,000-odd notifications that come to the ATSB, about 8,000 are classified as safety occurrences and entered into the database. Those that don't make the cut are usually duplicate-reports on the same occurrence from different sources, or they describe things that aren't assessed as a transport safety matter. The 8,000 that actually do constitute safety matters are reviewed, and any that warrant closer review are forwarded to investigators. Depending on the circumstances, about 100 will be investigated each year.

Periodically, people will wonder why a particular accident or incident is not being investigated - particularly if someone has died. However, the ATSB isn't budgeted to investigate everything. Investigations have to be selective The ATSB investigates events that are likely to yield the biggest safety benefit and provide important safety messages.

This is not to say, however, that a notification is of no use if the ATSB does not investigate it. Those thousands of occurrences (around 243,000 since 1969) are used in research and data analysis to allow a much better understanding of the trends and form of aviation safety in Australia.

So what exactly needs to be reported? And who needs to report it?

"Anyone who is 'a responsible person', as defined in the regulations (see below), is required to notify the ATSB of a 'reportable matter,'" explains Ethan. The regulations in question are the Transport Safety Investigation Regulations 2003, which, while not waiting room fare, do provide a definition for who constitutes a 'responsible person.' If you fit the criteria for being a 'responsible person', then it may pay you to acquaint yourself more fully with what you are obliged to tell the ATSB about, and when. If you know that the incident has already been reported, it doesn't need to be reported again, but it is your responsibility to make sure that the ATSB has been notified. And it is important that the notification reports are as accurate as you can make them. Submitting deliberately false or misleading information is actually a serious criminal offence under the Criminal Code. In fact, aiding, abetting, counselling, procuring or urging the submission of false or misleading information is also a serious offence. Some of the requirements may seem like more trouble than they're worth. Some of the reportable matters on their own may seem insignificant. But the occurrence reports all provide important insights into the health of the aviation system. They could also prove vital for our understanding of aviation safety issues, and how to address them.

So, the changes that we're proposing are important, not just for us, but also for you. You can find more information on the proposed amendments, and we're eager for your feedback.

Please forward your submissions to the contact officer below by 31 January 2010.

Contact Officer:

Steve Young
Manager, Notifications and Confidential Reporting
Email: regulation.consultation@atsb.gov.au

Phone: 02 6274 6471
Fax: 02 6274 6434

Postal address:
Australian Transport Safety Bureau
Notifications and Confidential Reporting
PO Box 967
Civic Square ACT 2608

Who has to notify the ATSB? Do you? The following persons are responsible persons in relation to reportable matters

a) A crew member of the aircraft concerned

b) The owner or operator of the aircraft

c) A person performing an air traffic control service in relation to the aircraft

d) A person performing a dedicated aerodrome rescue or firefighting service in relation to the aircraft

e) A person who
1. a. Is licensed as an aircraft maintenance engineer under the Civil Aviation Regulations 1988 or the Civil Aviation Safety Regulations 1998; and
2. b. Does any work in relation to the aircraft

f) A member of the ground handling crew in relation to the aircraft

g) A member of the staff of the Civil Aviation Safety Authority

h) The operator of an aerodrome

ATSB responds to WA Coroner’s findings

The ATSB has released its response to the Western Australia Deputy State Coroner’s inquest findings of 29 September 2010. The Coroner inquired into a fatal R22 helicopter accident that occurred on 28 September 2003 near Derby in Western Australia.

The ATSB has released its response to the Western Australia Deputy State Coroner's inquest findings of 29 September 2010. The Coroner inquired into a fatal R22 helicopter accident that occurred on 28 September 2003 near Derby in Western Australia.

The ATSB previously conducted an investigation into this accident and the ATSB's findings were fully agreed with by the Coroner.

The ATSB's response to the Coroner's recommendations are available on the investigation page.

Engine failure and air turn-back near San Francisco

The information contained in the preliminary report is derived from the initial investigation of the occurrence. Readers are cautioned that there is the possibility that new evidence may become available that alters the circumstances as depicted in this report.

On 30 August 2010 at approximately 2330 Pacific Daylight Time, a Boeing 747-438 aircraft, registered VH-OJP, departed San Francisco International Airport on a scheduled passenger service to Sydney, Australia. As the aircraft passed through 25,000 ft, the aircraft's number 4 engine sustained an internal mechanical failure, resulting in the energetic release of debris and puncturing of the engine casing and nacelle. The engine was shut down and the flight crew returned the aircraft to San Francisco, where it landed without further incident.

The number 4 engine had ruptured through the left and right sides of the turbine case and fairings, resulting in a large perforation in the right side of the engine nacelle and several smaller punctures through the left side.

Debris ejected through the hole in the right side of the engine had impacted the underside of the wing, producing superficial nicks and scratches to the wing skin. There was a puncture through the composite, leading-edge, variable-camber flaps and the associated torque tube was slightly bent.

There was no airframe damage inboard of the number 4 engine.

Read the preliminary report: Uncontained engine failure and air turn-back, near San Francisco Airport, United States of America, on 30 August 2010 | ATSB

Tailstrike Melbourne Airport, Vic. 20 March 2009 A6-ERG Airbus A340-541

The Australian Transport Safety Bureau (ATSB) is releasing its Interim Factual report into the tailstrike involving Airbus A340-500 aircraft, registered A6-ERG, during takeoff at Melbourne Airport, Vic. on the evening of 20 March 2009. The aircraft was being operated on a scheduled passenger flight from Melbourne to Dubai in the United Arab Emirates. This report builds on the facts advised in the report that was released on 30 April 2009 (ISBN 978-1-921602-43-6, available at www.atsb.gov.au).

The investigation has determined that the pre-flight take-off performance calculations were based on an incorrect take-off weight that was inadvertently entered into the aircraft's portable flight planning computer by the flight crew. Subsequent crosschecks did not detect the incorrect entry and its effect on performance planning, and the resulting take-off speeds and engine thrust settings that were applied by the crew were insufficient for a normal takeoff.

As a result of this accident, the aircraft operator has undertaken a number of procedural, training and technical initiatives across its fleet and operations; with a view to minimising the risk of a recurrence. In addition, the aircraft manufacturer has released a modified version of its cockpit performance-planning tool and is developing a software package that automatically checks the consistency of the flight data being entered into the aircraft's flight computers by flight crews.

The investigation has found a number of similar take-off performance-related incidents and accidents across a range of aircraft types, locations and operators around the world. As a result, the ATSB has initiated a safety research project to collate those events and examine the factors involved. The findings of that project will be released by the ATSB once completed.

The ATSB continues to work closely with the United Arab Emirates General Civil Aviation Authority (GCAA), the French Bureau d'Enquetes et d'Analyses (BEA), the operator and aircraft manufacturer. Ongoing investigation effort will include the examination of:

computer-based flight performance planning
human performance and organisational risk controls
reduced thrust takeoffs and the use of erroneous take-off performance data.

The remainder of the investigation is likely to take some months. However, should any critical safety issues emerge that require urgent attention, the ATSB will immediately bring such issues to the attention of the relevant authorities who are best placed to take prompt action to address those issues. In the interim, the ATSB has drawn this interim report to the attention of operators to remind them of the risks associated with calculating and entering take-off performance information.

2009/16: ATSB Second Interim Factual Report into the Qantas Airbus A330-303 in-flight upset, 154 km west of Learmonth WA, on 7 October 2008

The Australian Transport Safety Bureau has released a second Interim Factual Report into the accident involving the Qantas Airbus A330-303 in-flight upset, 154 km west of Learmonth WA, on 7 October 2008. The report summarises new activities conducted since the first Interim Factual Report that was released on 6 March 2009, and it should be read in conjunction with that previous report.

The aircraft (registered VH-QPA) was being operated on a scheduled passenger service (QF72) from Singapore to Perth. At 1240, while cruising at 37,000 ft, the aircraft experienced two uncommanded pitch-down events. The flight crew were able to quickly return the aircraft to level flight on each occasion and diverted to Learmonth, WA for a safe landing.

One flight attendant and 11 passengers were seriously injured, and eight other crew members and at least 99 other passengers received minor injuries. The injury rate and severity of injuries was significantly greater for those passengers who were not seated or not wearing seatbelts at the time of the first in-flight upset.

At least 60 of the 303 passengers were seated without their seatbelts fastened. Although there are legitimate reasons for passengers leaving their seats during a flight when the seatbelt sign is not illuminated, passengers are reminded to wear their seatbelts at all times when seated during a flight.

In addition to the initial procedures-based safety action taken by the aircraft manufacturer in response to this accident, Airbus is modifying the flight control primary computer (FCPC or PRIM) software used in the A330/A340 fleets to prevent any future similar problems leading to an uncommanded pitch-down event. An interim modification to the FCPC software standard is being installed in the operator's fleet, and the installation is expected to be completed by the end of November 2009. A later FCPC software standard to improve the treatment of all ADIRU parameters will be certified in mid to late 2010, and will then be retrofitted to the world-wide fleet of A330/A340 aircraft.

There has been speculation of a potential link between the QF72 accident off Learmonth on 7 October 2008 with the AF447 accident that occurred on 1 June 2009 on a flight from Rio de Janeiro to Paris. Although each of the accidents involved the same basic aircraft type, there are several important differences between the two accidents:

The ADIRUs on the two aircraft were different models, and constructed by different manufacturers.
The cockpit-effect messages and maintenance fault messages from both flights showed a significantly different sequence and pattern of events. For example, a series of maintenance messages that were transmitted by AF447 prior to the accident showed inconsistencies between the measured airspeeds and the associated consequences on other aircraft systems. No such messages were recorded by QF72. The airspeed sensors (pitot probes) on the two aircraft were different models made by different manufacturers.
The ATSB expects to release a final report into this accident in the second quarter of calendar year 2010. However, the ATSB will immediately bring any critical or significant safety issue(s)s to the attention of the relevant organisations best placed to address them, should any such issues arise. The ATSB will also publish details of any such issue(s).

Past Present Future

This publication celebrates the ten-year anniversary of the formation of the Australian Transport Safety Bureau (ATSB) on 1 July 1999. It is the story of the ATSB, and the earlier organisations that came together to form the ATSB a decade ago.

A proud history

The ATSB was formed on 1 July 1999 from the amalgamation of the Bureau of Air Safety Investigation (BASI), the Marine Incident Investigation Unit (MIIU), and non-regulatory parts of the Federal Office of Road Safety (FORS). In addition, an embryonic Rail Safety investigation capability was established. As this publication shows, each of the bodies that formed the ATSB already had a well-established record for excellence in their respective fields.

Publication details

Publication type	Safety Education Material
Publication mode	Corporate
Publication date	01/10/2009
ISBN	978-1-921095-87-0

Final ATSB report into the operational non-compliance at Perth Airport on 9 May 2008

The Australian Transport Safety Bureau (ATSB) has released its final investigation report into the serious incident at Perth Airport, WA on 9 May 2008, involving an approach and landing by a Boeing Company 737-800, registered PK-GEF, during a period of planned runway works.

The ATSB report found that the permanent runway 21 threshold and touchdown markings were not required to be obscured and were clearly visible to the flight crew. Those markings continued to provide approach and landing cues to the normal touchdown zone, which was located within the runway works area. The use of 6 m closed runway markings, in lieu of 36 m markings as recommended by the International Civil Aviation Organization (ICAO), increased the risk of a flight crew conducting a visual approach to the still-visible permanent threshold/touchdown area.

The report outlines a number of differences between the closed runway markings as recommended by ICAO Annex 14 Aerodromes, and the Civil Aviation Safety Authority (CASA) Manual of Standards (MOS) Part 139 Aerodromes.

A number of safety issues were identified as a result of the ATSB investigation. Safety action undertaken by the aircraft operator, the airport operator, and CASA in response to those safety issues should, when completed, reduce the risk of a similar event in the future.

Copies of the report can be downloaded from the ATSB's internet site at www.atsb.gov.au or obtained from the ATSB by telephoning 1800 020 616.

Tail Strike Melbourne Airport 20 March 2009, Airbus A340-500 aircraft, registered A6-ERG Media Conference

Today the Australian Transport Safety Bureau (ATSB) is releasing its Preliminary Factual report into the tail strike involving Airbus A340-500, A6-ERG, during take-off at Melbourne Airport at approximately 10:31 PM on the evening of 20 March 2009. The aircraft was being operated on a scheduled passenger flight from Melbourne to Dubai in the United Arab Emirates.

It is important to note that the information contained in the preliminary factual report, as the name suggests, is limited to preliminary factual information that has been established in the initial investigation of the accident. Caution should be exercised as there is the possibility that new evidence may become available that alters the circumstances as depicted in the report. Analysis of the factual information and findings as to the factors that contributed to the accident are subject to ongoing work and will be included in the final report.

The ATSB investigation, assisted by a number of other organisations and agencies, including the United Arab Emirates General Civil Aviation Authority (GCAA), the French Bureau d'Enquetes et d'Analyses (BEA), Emirates and Airbus, has determined that during the take-off roll on runway 16, the captain called for the first officer to rotate (lift off). However, when the aircraft was slow to respond, the captain commanded and applied maximum take-off thrust (TOGA). The aircraft's tail struck the runway and the aircraft lifted off shortly afterwards. During the take-off, the aircraft's tail contacted the ground beyond the end of the runway and a number of airport landing aids came into contact with the aircraft.

After becoming airborne, the flight crew received a cockpit message that a tail strike had occurred and so they contacted Air Traffic Control (ATC) and requested a return to Melbourne. The aircraft was radar vectored by ATC over Port Philip Bay to dump fuel to reduce the aircraft's weight for landing. While reviewing the aircraft's performance documentation in preparation for landing, the crew noticed that an incorrect weight had been inadvertently entered into the laptop when completing the take-off performance calculation prior to departure. The performance calculations were based on a take-off weight that was 100 tonnes below the actual take-off weight of the aircraft.

The result of that incorrect take-off weight was to produce a thrust setting and take-off reference speeds that were lower than those required for the aircraft's actual weight. During the return to land at Melbourne, a cabin crew member reported smoke in the cabin. The aircraft subsequently landed safely at 11:36 PM and was able to be taxied to the terminal where the passengers were disembarked. There were no reported injuries.

Damage to the aircraft included abraded skin to the rear, lower fuselage and damage to the rear pressure bulkhead. There was also damage to a fixed approach light, an instrument landing system (ILS) monitor antenna and the ILS localiser antenna.

The aircraft was fitted with a Flight Data Recorder (FDR), Cockpit Voice Recorder (CVR) and a Digital Aircraft Condition Monitoring System Recorder (DAR). The FDR was dislodged from its mounting in the rear of the aircraft during the tail strike and only recorded data up to that point. The CVR and DAR recorded data for the entire flight.

The investigation is continuing and will examine:

human performance and organisational risk controls
computer-based flight performance planning, including the effectiveness of the human interface of computer-based planning tools.
reduced power take-offs, including the associated risks and how they are managed.

The aircraft operator has informed the ATSB that based on their internal investigation, the following areas are under review:

human factors
training
fleet technical and procedures
hardware and software technology.

The investigation is ongoing and the ATSB continues to work closely with representatives from the UAE GCAA, French BEA, Emirates and Airbus. While the investigation is likely to take some months, should any critical safety issues emerge that require urgent attention, the ATSB will immediately bring such issues to the attention of the relevant authorities who are best placed to take prompt action to address those issues.

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