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 47 of the Bulletin features ten safety investigations:

Turboprop aircraft

• Collision with a vehicle, involving an Air Tractor AT-502B, VH‑FNX
• Collision with a pole involving an Air Tractor AT-502B, VH-PTF
• Flight crew incapacitation involving a SOCATA TBM 700, VH-YZZ

Piston aircraft

• Collision with coral reef involving a de Havilland Canada DHC-2, VH-AWI
• VFR into IMC involving a Piper PA28 aircraft, VH-TAU
• Low fuel event involving a Piper PA‑31P, VH-OGW

Helicopters

• Tail rotor strike of slung load involving a Eurocopter AS 350, VH‑NPS
• Wirestrike and collision with terrain involving a Robinson R44, VH-HXY

Separation issues

• Separation issue involving a de Havilland DH-82A (Tiger Moth), VH‑BJE and a Robinson R44, VH‑HOQ
• Separation issue between a Kavanagh Balloons E-300, VH-LPG, and freight train 4K26

Why the ATSB did this research

Through routine trend monitoring of safety occurrence reporting, the ATSB became aware of a potential issue surrounding the frequency of light aircraft engine failures and malfunctions (both Australian VH and recreationally-registered). To formally and more fully examine the contributing factors behind these statistical observations, the ATSB initiated this Aviation Research investigation (under the provisions of the Transport Safety Investigation Act 2003).

What the ATSB found

Over the 6-year study period between 2009 and 2014, 322 engine failures or malfunctions involving light aircraft were reported to the Australian Transport Safety Bureau (ATSB) and/or Recreational Aviation Australia (RA-Aus). These reports involved single-engine piston aeroplanes up to 800 kg maximum take-off weight. Aircraft powered by Jabiru engines were involved in the most engine failures or malfunctions with 130 reported over the 6 years. This represents about one in ten aircraft powered by Jabiru engines in the study set having reported an engine failure or malfunction. Reports from Rotax powered aircraft were the next most common with 87 (one in 36), followed by aircraft with Lycoming (58 – one in 35) and Continental (28 – one in 35) engines. When factoring in the hours flown for each of these engine manufacturers, aircraft with Jabiru engines had more than double the rate of engine failure or malfunction than any other of the manufacturers in the study set with 3.21 failures per 10,000 hours flown.

Unlike the engines of other engine manufacturers in this study, nearly half of the Jabiru engine failures or malfunctions related to a fractured component. Engine through-bolt failures were the most commonly reported failure mechanism in Jabiru powered aircraft with 21 through-bolt fractures reported between 2009 and 2014. Taking into account the number of aircraft registered in the study period, through-bolt failures occurred in about one in 55 Jabiru powered aircraft. Although originally designed to be replaced after 1,000 hours, 19 through-bolts failed before the 1,000 hour mark, with seven failing before 500 hours. At least four failures involved engines with upgraded 3/8 inch diameter through-bolt nuts. There were no failures reported involving the newer 7/16 inch diameter through-bolts which are used in currently manufactured engines (present in about 20 per cent of Jabiru engines).

What's been done as a result

Jabiru Aircraft Pty Ltd have designed and tested a modified 3/8 inch diameter through-bolt which incorporates aspects to alleviate the effects of thermal expansion and damp resonant vibrations.

The ATSB has issued recommendations to Jabiru Aircraft Pty Ltd and the Civil Aviation Safety Authority to reduce the risk of engine failure or malfunction in aircraft fitted with Jabiru engines and to assure future reliability of these engines.

Safety message

Owners and operators of light aircraft with Jabiru engines that have 3/8 inch diameter through-bolt configurations need to be aware of the continued elevated risk of a through-bolt failure leading to an engine failure or malfunction in flight. It appears that Jabiru engine service bulletins, requiring upgraded through-bolts of the same thickness and upgraded nuts to the 12-side ARP nuts, may not have fully addressed this issue. Thicker 7/16 inch through-bolts (installed in newly manufactured engines and recommended as a retro-fit for aircraft conducting flight training), appear to have improved the reliability of Jabiru engines, although future monitoring will provide more definite evidence.

Why the ATSB did this research

Occasionally pilots become incapacitated during flight. Incapacitations can arise from different reasons. They include the development of an acute medical condition, changes in environmental conditions during the flight, or the effects of a pre-existing medical condition. The effect of incapacitation on a pilot can be restricting their flight duties for the remainder of the flight, or for single-pilot operations, a collision with terrain.

This research report documents pilot incapacitation occurrences in high-capacity air transport, low-capacity air transport, and general aviation to help educate industry about the causes and risks associated with inflight pilot incapacitation.

What the ATSB found

In the past 5 years, there have been 23 pilot incapacitation occurrences reported per year on average. Nearly 75 per cent of the incapacitation occurrences happened in high-capacity air transport operations (about 1 in every 34,000 flights), with the main cause being gastrointestinal illness, followed by laser strikes. In the majority of the occurrences reported, the incapacitation was severe enough for the pilot to be removed from duty for the remainder of the flight. With multi-pilot crews in high-capacity operations, these occurrences usually had minimal effect on the flight.

Low-capacity air transport and general aviation had fewer occurrences with a wider variation of causes of incapacitation. These ranged from environmental causes, such as hypoxia, to medical conditions, such as heart attack. Furthermore, 70 per cent of pilot incapacitation occurrences in general aviation had an effect on flight operations, namely return to departure aerodrome or collision with terrain.

Safety message

This report highlights that pilot incapacitation can occur in any operation type, albeit rarely. In high-capacity air transport operations, the practice of ensuring all pilots on the same flight eat different meals prior to and during the flight has been an effective defence preventing all pilots on the same flight becoming incapacitated at the same time. Providing pilots with training in dealing with incapacitation events has been effective for when these events do occur. Pilots are also encouraged to report laser strikes to police and the Office of Transport Security. In low-capacity air transport operations, providing emergency training to non-flight crew, such as aeromedical nurses, is an important defence in case of pilot incapacitation. Finally, in general aviation, pilots are reminded to assess their fitness prior to flight. Assessment of fitness includes being aware of any illness or external pressures they may be experiencing.

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 45 of the Bulletin features 10 safety investigations:

Jet aircraft

• Stickshaker activation involving a Boeing 717 200, VH-NXM
• Loading event involving an Airbus A330, VH-QPJ

Turboprop aircraft

• Collisions with kangaroos involving a Fairchild SA227 (Metroliner), VH- HPE, and a King Air B200, VH-FDB

Piston aircraft

• Near collision between an Extra 300L, VH-KCF and a Robinson 44, VH-OLG
• Near collision involving a Cessna 172, VH-EOT, and a Jabiru J120, 24 5340
• Collision with terrain involving a Cirrus SR22, VH-OPX
• Partial power loss and forced landing involving a Cessna 172, VH-FPZ

Helicopters

• Near collision involving a Schweizer 269, VH-JXO, and a Military Lockheed AP-3C
• Loss of control involving a Robinson R44 helicopter, VH-ZWA

Remotely piloted aircraft systems

• In-flight break-up involving a DJI S900 remotely piloted aircraft

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.

In the 10-year period of 2005 to 2014, 254 aircraft have been involved in fatal accidents in Australia, leading to 374 fatalities. Most fatalities (240) were in CASA-registered (VH registrations) general aviation aircraft (including aerial agriculture, mustering, search and rescue, flying training, private and sport operations). Non-CASA registered recreational aircraft (aeroplanes, weight shift hang gliders, trikes, paragliders and powered parachutes, and gyrocopters) accounted for 98 fatalities. Commercial air transport (passenger regular public transport, charter and medical transport) accounted for 36 fatalities.

Across the 10-year period, the accident rate per hours flown was the highest for recreational aeroplanes, followed by aerial agriculture and private and sport aviation. However, all VH registered private and sport operations (including gliding) had a similar accident rate as that for all non-VH recreational flying combined. Recreational aircraft, private/sport, and aerial agriculture operation types were among the most likely to result in a fatal accident when considering the amount of flying activity. Within recreational aviation, half of all gyrocopters accidents were fatal and almost a third of weight shift aircraft accidents were fatal.

In 2014 alone, there was a total of 278 aircraft involved in accidents, and 202 involved in serious incidents (indicating an accident nearly occurred). Twenty aircraft were involved in fatal accidents, and another 28 resulted in serious injury. In 2014, Australia saw 28 fatalities and 36 serious injuries as a result of aviation accidents.

Commercial air transport recorded no fatalities in 2014. However, there were 27 accidents, an increase compared to the 10-year average of 19. Five of the accidents resulted in seven serious injuries. Most accidents (23) involved charter aircraft, and were mostly collision with terrain or failure of the landing gear. The 37 serious incidents (mostly aircraft separation and pilot incapacitation events) was a significant drop compared to the previous 2 years.

General aviation experienced 149 accidents in 2014 (the highest in 10 years), 11 of which were fatal (the lowest in 10 years) and another 15 resulted in serious injuries. These accidents led to 17 fatalities and 20 serious injuries. General aviation aircraft were involved in 118 serious incidents in 2014. In 2013 – the last year with available activity data – the general aviation accident rate per departure was almost five times that of commercial air transport. The year 2013 saw a significant decrease in the accident rate compared with the previous 6 years. However, the fatal accident rate was consistent with the 10-year average. Aerial agriculture, followed by private and sport aviation had the highest general aviation accidents rates, while flying training had the lowest.

The reporting of safety incidents to the ATSB from recreational (non-VH) aviation has increased more than tenfold in the last 10 years. This is due to both the growth in recreational flying and improving awareness of reporting requirements. In 2014, 99 accidents were reported, nine of which were fatal and another eight leading to serious injuries. Most accidents involved aeroplanes, as these are the most common recreational aircraft.

Download the PDF report

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 46 of the Bulletin features ten safety investigations:

Jet aircraft

• Pre-flight planning event involving a Boeing 737, VH-YIU

Turboprop aircraft

• Weather related event involving a Bombardier DHC-8, VH-XFQ

Piston aircraft

• Collision with terrain involving a Beech A36, VH-PAK
• Fuel exhaustion event involving a Cessna 182, VH-DNZ
• Fuel management issue, involving a PA-31-350, VH-HJH
• Wheels-up landing involving a Cessna 172RG, VH-HTP
• Flight path infringement involving a Cessna 172M, VH-EJM and a vehicle
• Partial engine failure involving a Gippsland Aeronautics GA-8, VH-FGN
• Aircraft control issue involving a Liberty XL-2, VH-CZS

Helicopters

• Collision with terrain involving a Robinson R22, VH-NCL

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 44 of the Bulletin features 10 safety investigations:

Piston aircraft

• Landing gear malfunction involving a Cessna 210, VH-SMP
• Collision with terrain involving a Victa 115 Airtourer, VH‑MUV
• Separation issue involving a Pacific Aerospace CT/4B, VH-YCU, and a Diamond DA 40, VH-UNV
• Collision with terrain during landing, involving a PA32 aircraft, VH-BDG
• Engine failure and collision with terrain involving a Cessna 210, VH‑ERU
• Collision with terrain involving a Grumman G164, VH-LKN
• Separation issue involving a Cessna 404, VH-ANM, and a Cessna 172, VH MJK

Helicopters

• Engine failure involving an Enstrom 280, VH-YHD
• Windscreen fogging and collision with terrain involving a Robinson R22, VH-RBT
• Loss of control involving a Bell 206L3, VH-BLV

Introduction

The ATSB Annual Report 2014–15 outlines performance against the outcome and program structure in the 2014–15 Infrastructure and Regional Development Portfolio Budget Statements.

Chief Commissioner’s review 2014–15

This was the ATSB’s sixth year as a fully independent body within the Infrastructure and Regional Development portfolio. In addition to the continuing search for the missing Malaysia Airlines Flight MH370, 2014–15 saw the completion of a range of significant investigations and some significant governance changes for the ATSB.

In July 2013, I requested the Transportation Safety Board of Canada (TSB) to conduct an independent objective review of our safety investigation methodologies and processes. I asked that they benchmark Canadian methodologies with ours and compare both with international standards. The TSB looked, in particular, at three of our substantial investigations including the ditching of a Pel-Air Westwind jet off Norfolk Island in 2009 (AO-2009-072). This investigation had been strongly criticised in some quarters and was the subject of a report by the Senate Rural and Regional Affairs and Transport Committee.

The TSB report, released in December 2014, found that the ATSB’s investigation methodology and analysis tools represent best practice, and have been shown to produce very good results.

At the same time, the report highlighted room for improvement, particularly in relation to the way our processes were applied to the Pel-Air ditching investigation.

In response to the TSB review, the ATSB decided to reopen the investigation into the Pel‑Air accident. A completely new team was appointed to review the original investigation and associated report in light of any fresh evidence, relevant points from the TSB review and other recent aviation reviews. The ATSB expects to complete the reopened investigation in the first quarter of 2016.

After carefully considering the other findings and recommendations of the TSB report, the ATSB accepted all of them. We have worked our way methodically and carefully through implementation of the recommendations of the TSB review, resulting in improvements to the future work of the ATSB. Being able to compare our approaches and learn from our respected colleagues in Canada has been a valued opportunity.

In November 2013, in keeping with a pre-election commitment, the Deputy Prime Minister and Minister for Infrastructure and Regional Development, the Hon Warren Truss MP, commissioned a review of Australia’s aviation safety regulation system. This was to see how our safety regulation system is placed to deal with this economically important industry. Following completion of the report the ATSB contributed to the Government’s response.

On 3 December 2014, the Deputy Prime Minister made a statement in Parliament confirming that the Government fully supports the vital role of the ATSB. To give effect to a pre-election commitment, he undertook to appoint an additional Commissioner with aviation experience and to issue a new Statement of Expectations.

In accordance with the Deputy Prime Minister’s announcement, Mr Chris Manning was appointed as a Commissioner with effect from 9 March 2015. Chris has brought a wealth of experience in aviation as an expert pilot and prominent aviation manager, and from his arrival has made a very valuable contribution to our work.

The Deputy Prime Minister issued a revised Statement of Expectations on 19 April 2015. The statement largely confirmed our existing focus and direction, but also required us to implement the relevant parts of the Government’s response to the Aviation Safety Review Report and the agreed recommendations of the TSB review. The ATSB’s response to the Statement of Expectations is set out in our Corporate Plan.

The issuing of a Corporate Plan was part of our implementation of the Public Governance, Performance and Accountability Act 2013 (PGPA Act). To meet the requirements of the new PGPA Act, we have implemented more comprehensive business planning and risk management processes. These are all being managed consistently with our safety priorities, which have been at the centre of our SafetyWatch communication and safety awareness direction for the last three years.

The search for Malaysia Airlines Flight MH370

The search for the missing Malaysia Airlines Flight MH370 in the Southern Indian Ocean has been a major commitment during the whole year. It has involved complex and challenging activities including:

• conducting ground-breaking technical analysis to determine the appropriate search area
• determining the processes and standards necessary to undertake an unprecedented underwater search
• selecting highly capable contractors with the expertise and equipment to conduct the search
• continuing project and financial management
• dealing with the incredible level of interest and enquiry from all over the world.

We have worked with our Minister and our Malaysian and Chinese counterparts to keep them informed of the search progress and enable joint decisions to be made when required.

Aviation

During the year we completed 40 aviation investigations and more than 100 short factual investigations.

The most significant of these was the crash of a Robinson R44 helicopter at Bulli Tops on 21 March 2013 (AO-2013-055). This, as well as two previous similar accidents involving R44 helicopters, highlighted the danger of rigid fuel tanks in low-impact helicopter crashes, where post-impact fires may make otherwise survivable accidents deadly. We confirmed this trend with detailed statistical analysis of similar accidents in Australia and the US over a 10-year period.

While the Civil Aviation Safety Authority (CASA) had recommended that owners and operators implement the manufacturer’s service bulletin recommendation to replace the fuel tanks with bladder-type tanks that would improve resistance to post-impact fuel leaks, it was clear that they would be unlikely to meet the 30 April 2014 deadline. Accordingly, the ATSB recommended that CASA mandate the requirement by the due date. As a result, all R44 helicopters in Australia are now compliant.

Following this action, other safety authorities in South Africa, New Zealand and Europe have also mandated the change. The ATSB has issued safety recommendations to the US Federal Aviation Administration that they also take action to mandate fitting of bladder-type fuel tanks. The outcome of this investigation illustrates the importance of our investigations and the far-reaching influence safety investigations can have in ensuring transport safety for all travellers, not only those in Australia or our immediate region.

Other significant aviation investigations have also led to improvements in the way air ambulance and rescue services undertake winching of patients. There have also been changes to air traffic control procedures and training of air traffic controllers following our investigation into a loss of separation assurance.

Marine

During the year we completed five marine investigations. These were mainly concerned with marine work practices and confirmed that ships are inherently dangerous places of employment.

It is essential that employees implement sound risk management and occupational health practices. The most serious of these incidents was the unexpected deployment of a lifeboat and the subsequent serious injury to an employee.

Errors by maritime pilots and other ship operators are still contributing to collisions and other mishaps.

Rail

We completed 20 rail investigations this year. Some of these concerned derailments, raising serious questions about the way operators are building and maintaining their rail networks.

Disappointingly, we are still seeing many instances where breaches of safe work practices put maintenance crews and operators at risk. This issue has been one of our safety priorities for the last three years. Continuing notifications suggest the existence of broader safety issues associated with work on track. Consequently, we have initiated a safety issues research project looking into the protection issues that provide for safe work on track. The project has commenced with an analysis of our statistical data which aims to present the Australian experience with safe work occurrences and highlight the key areas where further attention should be focussed.

We continue to work on a national approach to rail safety investigation and have been holding negotiations with Western Australia and Queensland to complete the process of establishing a unified national system of rail safety investigation.

Resource constraints

As reported last year, our resource situation led us to reduce our workforce by approximately 12 per cent. We have experienced further budgetary restraint this year despite the additional resources provided to undertake the search for MH370. Budget restraints have had a significant effect on our responsiveness and flexibility and continues to affect our capacity to conduct investigations. Our performance statistics for the year show this very clearly, particularly in regard to the timeliness of our investigations. This year, I have incorporated a table in our performance reporting which shows our longitudinal results over the past three years.

Safety priorities

Through our SafetyWatch initiative we maintain a continuing focus on nine safety priorities:

• flying with reduced visual cues
• general aviation pilots
• handling the approach to land
• data input errors
• safety around non-controlled aerodromes
• under-reporting of occurrences
• safe work on rail
• marine work practices
• maritime pilotage.

Outlook for 2015–16

Resources continue to be constrained. It is a simple fact that with fewer resources we can do fewer investigations, or we must constrain the scope of some of the investigations we do undertake. More than ever, we need to choose those accidents or incidents that have the greatest potential to yield the greatest safety benefit. There remains a substantial risk we will miss an important issue. To minimise this risk, we are focussing strongly on analysis of our data and our investigation findings to identify emerging trends. Our short investigations also play an important role in enabling us to take a closer look at accidents and serious incidents which have the potential for more detailed systemic investigation. The importance of the work has not diminished, and I am pleased that the Government has reaffirmed the value of our work.

Once again, I would like to acknowledge the first-class work of our investigators and other staff, and to thank them for their continued commitment to the ATSB. I am also grateful for the continuing attention, support and wise counsel of my fellow Commissioners.

Martin Dolan

Chief Commissioner/CEO

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 42 of the Bulletin features 10 safety investigations:

Jet aircraft

• Data input error involving a Boeing 737, VH-XZI

Piston aircraft

• Engine failure involving a de Havilland Canada DHC-1 (Chipmunk), VH-RVY
• Near collision between a Beech 76 aircraft, VH-ZUA and a Eurocopter AS350 helicopter, VH-SWX
• Separation issue involving a Cessna 208, VH-HLN, and a Cessna 207, VH-WOX
• VFR into IMC involving a Beech A36, VH-ANX
• Collision with terrain involving a Cessna 182, VH-AHC

Helicopters

• Tail rotor malfunction involving a Robinson R22, registration VH-HPH
• Collision with terrain involving a Robinson R22, VH-APP
• Wirestrike involving a Robinson R44, VH-LOL

Remotely piloted aircraft systems

• Loss of operator control involving an Aeronavics SkyJib 8 remotely piloted aircraft

The Australian Airports Association (AAA) commissioned preparation of this Airport Practice Note to provide aerodrome operators with species information fact sheets to assist them to manage the wildlife hazards at their aerodrome. The species information fact sheets were originally published in June 2004 by the Australian Transport Safety Bureau (ATSB) as Bird Information Fact Sheets.

The AAA was prompted to revise and add additional fact sheets for supplementary species by the release of the ATSB Australian aviation wildlife strike statistics 2004 – 2013 report. This report listed Kites and Bat/ Flying Foxes as having the largest overall number of strikes in the 2012-2013 reporting period representing a demonstrated risk to safe operations. As a result of this report the AAA partnered with Avisure in consultation with the ATSB to update the existing fact sheets and create new species information fact sheets focused on managing the strike risk of these species at Australian airports.

These new and revised fact sheets provide airport members with useful information and data regarding common wildlife species around Australian aerodromes and how best to manage these animals. The up-to-date suite of species information fact sheets will provide aerodrome operators with access to data, information and management techniques for the species posing the greatest risk to safe aerodrome operations in Australia. It is hoped that this document will be a worthwhile and useful asset to aerodrome operators across Australia and the AAA would like to acknowledge the contribution of Avisure and the ATSB in the development of this project.