The first people to arrive at an aircraft accident site can render valuable assistance to minimise injury and loss of life, reduce property loss through damage and prevent the loss of clues and evidence that are vital to determining the reason for the accident.

Often, emergency services personnel (police, fire brigade and ambulance, and their Defence Force equivalents) are the first trained personnel to arrive at aircraft accident sites. This online guide (note: printed copies no longer available - PDF version ONLY) has been prepared by the Australian Transport Safety Bureau (ATSB) and the Defence Flight Safety Bureau (DFSB), formerly the Directorate of Defence Aviation and Air Force Safety (DDAAFS), to assist these personnel to:

• understand the reporting requirements for military and civil aircraft accidents
• have an awareness of hazards at an aircraft accident site
• consider how to manage the various hazards
• understand the requirements of the Transport Safety Investigation Act 2003 (TSI Act) and the Defence Aviation Safety Manual
• manage and control the accident site to preserve essential evidence necessary for the ATSB or DFSB to conduct an effective investigation.

This online guide also features a 'what to do' checklist in its centre pages for easy reference. The checklist(Opens in a new tab/window) (146 KB) should help personnel undertake essential actions as safely as possible.

Role of first responders

There are three main components to the work of first responders to the scene of an aviation accident:

1. Reporting the accident to the ATSB or DFSB.
2. Coordination of the accident site including rescuing any survivors, managing fire and hazardous materials and ensuring that the site is secured.
3. Protection of the aircraft wreckage and associated evidence so that an effective investigation can be conducted.

This online PDF guide assumes that first responders will apply their own expert training to deal with victims, manage hazards and control the site. It offers specific advice that may be helpful in identifying and managing the particular hazards and risks associated with an aircraft accident. It also contains important advice about preserving evidence at the site.

While there are mandatory requirements in the Transport Safety Investigation Act 2003 in regard to civil transport accidents, the guidance material contained in this document does not override specific policies or procedures developed by police, emergency services or other agencies, such as airport authorities.

How can I report?

CIVIL: All civil aircraft accidents must be reported to the ATSB via the toll free number: 1800 011 034.

MILITARY: Contact the DFSB Duty Officer on 02 6144 9199, or by other methods as detailed in this publication.

Guidelines for aerodrome operators

The required actions by an aerodrome operator in the event of an aviation accident are detailed here.

The Aviation Short Investigation Bulletin covers a range of the ATSB’s short investigations and highlights valuable safety lessons for pilots, operators and safety managers.

Released periodically, the Bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken. The Bulletin also highlights important Safety Messages for the broader aviation community, drawing on earlier ATSB investigations and research.

Issue 58 of the Bulletin features 10 safety investigations:

Jet aircraft

• Severe turbulence involving Airbus A330, B-5921
• Loading related event involving Airbus A320, VH-VQC
• Runway incursion involving Fokker F28 MK 100, and vehicle 

Turboprop aircraft

• Fumes event involving Bombardier DHC 8, VH SBB
• Near collision involving Hawker Beechcraft Corporation B300C, VH-NAO, and a work safety officer
• Runway undershoot involving Fairchild SA226, VH-SSV

Helicopters

• Tail rotor driveshaft failure involving Bell 206, VH-CHO

Separation issues

• Separation issue involving Bombardier DHC-8, VH-QOV, and Eurocopter MBB-BK 117, VH-EHQ
• Loss of separation involving Bombardier DHC-8, VH-LQG, and Boeing 777, ZK-OKF

Communication issues

• Unlawful communications

Note for the second edition: Since the publication of the ATSB report A safety analysis of remotely piloted aircraft systems 2012 to 2016 (AR-2017-016) in March 2017, the ATSB has observed a significant change in the trend of reported occurrences involving Remotely Piloted Aircraft Systems (RPAS). Contrary to the previous report, our most current forecasts predict the total number of RPAS occurrences reported to the ATSB in 2017 to be comparable to 2016.

Due to this new information and the lack of data present in the public arena, the ATSB opted to publish a new edition of the report detailing our current understanding of the implications to transport safety associated of RPAS activity in Australia. Data presented in this edition is current to the end of June 2017.

Why the ATSB did this research

The growth in the number of remotely piloted aircraft systems (RPAS) in Australia is increasing rapidly. This presents an emerging and insufficiently understood transport safety risk.

The ATSB aims through this report to present data and analysis to further understanding of the implications for transport safety associated with the continual growth of RPAS activity in Australia.

What the ATSB found

Although accurate assessments of the number of RPAS in Australia is not possible, using proxy data, it is clear that the number of RPAS in Australia is growing rapidly each year. Compared to 2016, there will be a possible doubling in the number of systems in Australia by the end of 2017.

In association with the level of growth, the number of RPAS‑related safety occurrences reported to the ATSB increased rapidly during the 2012 to 2016 period. However, the first half of 2017 saw significantly fewer occurrences than predicted given the previous data. Current forecasts—incorporating data up to the end of June 2017—predict the number of RPAS occurrences reported to the ATSB in 2017 to be comparable to 2016.

Over half of all occurrences from January 2012 to June 2017 involved near encounters with manned aircraft, almost three‑quarters occurred between January 2016 and June 2017. Most occur in capital cities, Sydney in particular, and above 1,000 ft above mean sea level (AMSL).

To date, there have been no reported collisions between RPAS and manned aircraft in Australia.

The next most common type of occurrence involved collisions with terrain, almost half of which results from a loss of control of the RPAS.

The consequences of collisions between RPAS and manned aircraft are not yet fully understood. World-wide, there have been five known collisions. Three of these resulted in no damage beyond scratches. However, one collision with a sport bi-plane in the United States in 2010 resulted in a crushed wing. Fortunately, the aircraft landed safely. Less fortunately, a Grob G 109B motor glider had a wing broken by an RPAS collision in 1997 in Germany, resulting in fatal injury to the two people on board.

Due to the rarity of actual collisions, there is limited data from which to draw conclusions regarding the possible outcomes. Laboratory testing and mathematical models produced by various agencies have been used in conjunction with abundant aircraft birdstrike data in an attempt to assess the probable consequences of a collision.

RPAS collisions with high capacity air transport aircraft can be expected to lead to an engine ingestion in about eight per cent of strikes. The proportion of ingestions expected to cause engine damage and engine shutdown will be higher than for bird ingestion (20 per cent of ingestions).

RPAS have the potential to damage a general aviation aircraft’s flight surfaces (wings and tail), which could result in a loss of control. Furthermore, a collision with a general aviation aircraft’s windscreen poses a high risk of penetration.

A collision with a helicopter’s windscreen poses a similar penetration risk. Any impact on a helicopter’s tail rotor could cause catastrophic failure of the rotor.

Safety message

The operation of remotely piloted aircraft is an emerging risk to transport safety that requires close monitoring as the popularity of these aircraft continue to rapidly grow.

 

 

Why the ATSB did this research

This is the second in a series of research investigations looking at technical failures reported to the ATSB. This report reviews power plant problems affecting turboprop‑powered aircraft between 2012 and 2016.

By summarising power plant-related occurrences, this report provides an opportunity for operators to compare their own experiences with others flying the same or similar aircraft types, or aircraft using the same engines. By doing so, the ATSB hopes that the wider aviation industry will be able to learn from the experience of others.

What the ATSB found

A review of power plant‑related occurrences reported to the ATSB showed that there were 417 occurrences involving turboprop-powered aircraft between 2012 and 2016 (83 per year on average). The subset of occurrences involving operators whose flight hours were known consisted of 314 occurrences in the four years between 2012 and 2015 (79 per year on average). With a combined total of just over 1.4 million flight hours for these aircraft in this timeframe, this subset equates to approximately 2.2 occurrences every 10,000 flight hours.

The vast majority of all the 417 occurrences (96%) were classified as ‘low-risk rating’ occurrences with a low or no accident outcome, however, there were four classified as ‘medium-risk’ and three as ‘high-risk’. The three occurrences classified as high-risk occurrences all involved engine failures or malfunctions with forced/precautionary landings in single‑engine Cessna 208 (Caravan) aircraft. There were no occurrences classified as ‘very high-risk’.

The two occurrences in the set that resulted in any injury (both minor) were the result of engine failure or malfunctions and collision with terrain occurrences in aerial agricultural operations. The five occurrences classified as ‘accidents’ all involved aerial work operations, four in aerial agriculture and one in emergency medical services operations.

One aircraft type was found to have a rate of 13.9 power plant-related occurrences per 10,000 hours flown, more than double the rate of any other aircraft type. However, with only four occurrences between 2012 and 2015, the high rate is due to relatively very low flight hours for this aircraft. All four of these occurrences were classified as incidents (rather than accidents or serious incidents) and classified as low risk rating occurrences. Additionally, the sole operator of this aircraft type in Australia advised the ATSB that the fleet was retired in 2017 and replaced with a newer turbofan alternative.

Safety message

Timely and vigilant reporting of all technical problems is encouraged to ensure as much information as possible is collected so as to enable a better understanding of the failures. Of particular importance in technical occurrences are the follow-up reports from engineering inspections provided to the ATSB. These are often the only way that the root cause of the problem can be determined.

Why we have done this report

Occurrences involving aircraft striking wildlife, particularly birds, are the most common aviation occurrence reported to the Australian Transport Safety Bureau (ATSB). Strikes with birds continue to be a potential safety risk and present a significant economic risk for aerodrome and airline operators. The aim of the ATSB’s statistical report series is to provide information back to pilots, aerodrome and airline operators, regulators, and other aviation industry participants to assist them with managing the risks associated with bird and animal strikes. This report updates the last edition published in 2014 with data from 2014 – 2015.

What the ATSB found

Between 2006 and 2015, there were 16,069 birdstrikes reported to the ATSB, most of which involved high-capacity air transport aircraft. Both the number and rate of birdstrikes per 10,000 movements in high-capacity operations have increased markedly in the past two years 2014­ – 2015. In contrast, the number of birdstrikes in low-capacity operations and general aviation has remained relatively consistent. In the two years since 2013, the rates for six of the ten major airports have increased relative to ten year averages. The largest increase in the rate of birdstrikes was observed at Cairns, Canberra, Darwin, Gold Coast and Sydney.

Domestic high-capacity aircraft were those most often involved in birdstrikes, and the birdstrike rate per aircraft movement for these aircraft was significantly higher than all other categories. The number of engine bird ingestions for high-capacity air transport operations had been increasing until 2011, but has since decreased slightly. Still, about one in ten birdstrikes for turbofan aircraft involved a bird ingested into an engine.

The four most commonly struck types of flying animal in the 2014 to 2015 period were: bats/flying foxes, Swallow/Martins, Kites, and Lapwings/Plovers. Swallows and Martins had the most significant increase in the number of reported birdstrikes per year in the last two years, with these species being involved in an average of 96 birdstrikes per year for 2014 and 2015 compared with 65 per year on average across the entire 10-year reporting period. Galahs were more commonly involved in birdstrikes of multiple birds, with more than 38 per cent of Galah strikes involving more than one Galah. However, larger birds were more likely to result in aircraft damage.

This report presents a new species mass analysis which estimates that over the ten years between 2006 and 2015, 766 kg of flying animals were struck per year by aircraft in Australia. Additionally, for every 1 kg increase in animal mass, the likelihood of a birdstrike causing damage increases by 12.5%.

Compared to birdstrikes, ground-based animal strikes are relatively rare. The most common animals involved were hares and rabbits, kangaroos, wallabies, and dogs / foxes. Damaging animal strikes mostly involved kangaroos, wallabies and livestock.

Safety message

Australian aviation wildlife strike statistics provide a reminder to everyone involved in the operation of aircraft and aerodromes to be aware of the hazards posed to aircraft by birds and non-flying animals. Timely and thorough reporting of birdstrikes is paramount. The growth of reporting to the ATSB that has been seen over the last 10 years has helped to better understand the nature of birdstrikes, and what and where the major safety risks lie. This assists the aviation industry to better manage their safety risk.  Over the ten years from 2006 to 2015, 42% of all birdstrikes reported to the ATSB contained no species information.  The more accurately this information is provided to the ATSB, the more accurate and useful reports like this one will be.

The Aviation Short Investigation Bulletin covers a range of the ATSB’s short investigations and highlights valuable safety lessons for pilots, operators and safety managers.

Released periodically, the Bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken. The Bulletin also highlights important Safety Messages for the broader aviation community, drawing on earlier ATSB investigations and research.

Issue 56 of the Bulletin features ten safety investigations:

Jet aircraft

• Engine malfunction and in-flight shutdown involving Boeing 777, A6-EGA
• Take-offs without runway lighting involving Embraer ERJ-135, VH-JTG

Turboprop aircraft

• Synthetic vision display error involving Pilatus PC-12, VH-OWA 
• Severe turbulence involving Bombardier DHC-8, VH-LQM            

Piston aircraft

• Wheels up landing involving Cessna 210, VH-UPN           
• Engine failure and collision with terrain involving Ryan Aeronautical Company STA-SPL, VH-SQD     

Separation issues

• Taxiing collision involving Boeing 717, VH-NXN, and Fokker 100, VH-NHF
• Aircraft separation issues involving Embraer ERJ 190, VH-ZPJ, and GippsAero GA-8, VH-XGA             
• Near collision involving Cessna 172S, VH-USL, and parachutists  

Remotely Piloted Aircraft

• Loss of control involving remotely piloted aircraft Pulse Aerospace Vapor 55

The Aviation Short Investigation Bulletin covers a range of the ATSB’s short investigations and highlights valuable safety lessons for pilots, operators and safety managers.

Released periodically, the Bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken. The Bulletin also highlights important Safety Messages for the broader aviation community, drawing on earlier ATSB investigations and research.

Issue 57 of the Bulletin features ten safety investigations:

Jet aircraft

• Taxiing incident involving Airbus A330, 9M-XXK
• Emergency evacuation involving Fokker F28, VH-NHY

Turboprop aircraft

• Engine failure involving Fairchild SA227, VH-VEU
• Misaligned take-off involving Beechcraft B200, VH-XGV
• Engine failure and forced landing involving Cessna 208, VH-TYV

Piston aircraft

• Forced landing involving Cessna 188, VH-BCT

Helicopters

• Collision with terrain involving Robinson R44, VH-YMJ
• Ground strike involving Robinson R44, VH-HHZ

Separation Issues

• Near collision involving Pilatus BN2, VH-IOA, and Bombardier DHC-8, VH-ZZJ

Remotely Piloted Aircraft

• Collision with terrain involving Lockheed Martin Stalker XE UAS

Detecting an unsecured canopy prior to take-off could prevent in-flight control issues resulting in injury or aircraft damage.

What happened

On 14 October 2014, a Van’s Aircraft Inc. (Van’s) RV-6A departed Moorabbin Airport, Victoria on a local flight. Shortly after reaching 2,900 ft, the aircraft descended rapidly and a witness reported observing objects falling from the aircraft. The aircraft collided with the ground next to a house 8 km south of Moorabbin. The pilot was fatally injured and the aircraft was destroyed. Members of the public found a number of items away from the accident site that belonged to the pilot.

Tip-up canopy open

(Source: Supplied)

Why did it happen

The liberation of the items from the aircraft’s interior indicated that the tip-up (forward-hinged) canopy likely opened in‑flight. While the ATSB was unable to determine how the canopy opened and the effect on aircraft control, there were indications the pilot was attempting to respond to the situation. However, for reasons undetermined, recovery did not occur before the impact with the ground. The ATSB found that, in a number of Van’s models, the in-flight opening of a tip-up canopy may potentially result in a significant pitch down tendency that may affect aircraft control.

Safety advisory notice

: The consequences when an aircraft canopy opens in-flight, including on other than Van’s aircraft types, can vary from being relatively benign to significant, such as a sudden pitch down. In any event, in the first instance, pilots should expect an element of startle and distraction. The detection of an unsecured canopy prior to take-off could prevent in-flight control issues resulting in injury or aircraft damage. The ATSB advises pilots to be vigilant and to confirm the security of their aircraft’s canopy prior to take-off.

Check the security of your canopy

The in-flight opening of canopies in a number of Van’s aircraft models highlights the varying consequences in the case of such occurrences. The result can vary from being relatively benign to significant. While this investigation focused on Van’s aircraft, the implications are applicable to all aircraft fitted with a canopy, in particular, a tip-up canopy. Such occurrences serve as a reminder for pilots to check the security of their aircraft’s canopy prior to take‑off. Additional measures, such as the incorporation of a specific pre-flight checklist item, and/or the installation of a canopy-open warning device, have the potential to assist pilots detect an unintentionally-open canopy.

The ATSB encourages pilots who experience a canopy opening in-flight to notify the aircraft manufacturer and, in the case of difficulty controlling their aircraft, the ATSB in accordance with the reporting requirements of the Transport Safety Investigation Act 2003. This will allow for a greater understanding of the safety implications of these types of occurrences.

Read more about this ATSB investigation: AO-2014-164

Safety issue: Potential adverse effects of a tip-up canopy opening in-flight

Why have we done this report

Thousands of safety occurrences involving Australian-registered and foreign aircraft are reported to the ATSB every year by individuals and organisations in Australia’s aviation industry, and by the public. The aim of the ATSB’s statistical report series is to give information back to pilots, operators, regulators, and other aviation industry participants on what accidents and incidents have happened, how often they are happening, and what we can learn from them.

What the ATSB found

In 2015, Australia had 31 fatalities and 32 serious injuries – 28 aircraft were involved in fatal accidents and a further 28 in an accident resulting in serious injuries. There was a total of 227 aircraft involved in accidents, and 185 involved in serious incidents (indicating an accident nearly occurred).

• Commercial air transport had one fatality from nine accidents.
• General aviation had 12 fatalities from 130 accidents.
• Recreational aviation had 18 fatalities from 76 accidents.

For commercial air transport, 2015 had the lowest number of accidents in the study period (2006–2015). Seventeen of the 19 fatalities (2006–2015) involved aircraft conducting charter operations.

The majority of fatalities, in the 10‑year period, occurred within general aviation. Around 20 per cent of fatal accidents resulted from a loss of control.

Growth in recreational (non‑VH) flying and improving awareness of reporting requirements, led to more than a tenfold increase in the number of recreational safety incidents reported to the ATSB between 2006–2015.

The number of remotely piloted aircraft accidents and incidents increased significantly – from 14 occurrences within eight years (2006–2013) to 37 within the last two years (2014–2015) of the study period.

From 2006 to 2014 (activity data was not available for 2015), recreational aircraft, search and rescue, private/business and sports aviation, and aerial agriculture operation types had the highest fatal accident rates (per hours flown). For all accidents, the highest accident rates occurred with recreational aeroplanes, followed by aerial agriculture, private/business and sport aviation, and recreational gyrocopters.

• Around 40 per cent of all recreational gyrocopter accidents resulted in fatalities and almost one‑quarter of weight shift aircraft accidents were fatal.
• The highest general aviation accident rate in the study period was in 2014. However, that year also had the lowest fatal accident rate.
• In 2014, the flying training accident rate was more than double that of any year in the previous eight.

What happened

In the early hours of 14 July 2015, the offshore support vessel (OSV) Skandi Pacific was loading cargo from an oil rig about 165 km off Australia’s north-west coast. As the weather deteriorated, cargo operations were stopped and the OSV moved a short distance from the rig. Two crewmembers then began securing the cargo on the vessel’s aft deck.

While securing the cargo, the crewmembers slackened the securing chain they had used to secure the containers on the starboard side to better secure the entire stow. Shortly after, two large waves came over Skandi Pacific’s open stern, shifting the unsecured containers forward. One crewmember was trapped between the moving containers, chains and a skip and suffered fatal crush injuries.

Skandi Pacific's aft deck

Source: DOF Management

Why did it happen

The deteriorating weather conditions had resulted in the cargo operations being stopped. After the crewmembers had lashed the cargo they found two mini-containers forward were not properly secured. To secure the containers, they decided to use a secondary chain, by securing it to the crash barrier then to the primary chain. When tightened, this chain would bring the primary chain in tight against the mini-containers. Their plan required slackening the primary chain to secure the secondary.
However, the sequence of working exposed them to high risk if water was shipped on Skandi Pacific’s aft deck. The crewmember attempting to fasten a securing chain forward of the two unsecured mini-containers was in a position of danger when waves came over the vessel’s open stern.

The Australian Transport Safety Bureau (ATSB) found that vessel’s managers had not adequately assessed the risks associated with shipping seas over the vessel’s stern while securing cargo on this type of vessel (the OSV had an open stern). Further, there were no clearly defined limits for excessive water on deck that necessitated stopping operations, leaving individuals to make difficult, and necessarily subjective, decisions about whether or not to stop work.

The ATSB investigation also identified that the vessel’s safety management system procedures did not contain clearly defined weather limits for working or securing cargo in adverse weather.

Safety advisory notice

: The Australian Transport Safety Bureau advises the masters, owners and operators of all offshore support vessels to ensure that the risks associated with working on the aft deck of vessels with open sterns are adequately assessed.

Read more about this ATSB investigation: Fatality on board Skandi Pacific, off the Pilbara coast, Western Australia on 14 July 2015.