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 55 of the Bulletin features ten safety investigations:
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 54 of the Bulletin features ten safety investigations:
This was the ATSB’s seventh year as a fully independent body within the Infrastructure and Regional Development portfolio. 2015–16 also marked the final year of Martin Dolan’s tenure as the ATSB’s Chief Commissioner. While Martin’s real and significant contributions to improving transport safety have been widely acknowledged, it was his passion, energy and commitment to maintaining the ATSB’s reputation as a world-leading safety investigation body that will be remembered as his most enduring qualities.
Ongoing challenges
As foreshadowed through the ATSB’s 2015–16 Corporate Plan, the ATSB entered this reporting period faced with an operating environment of continuing growth in, and progressive changes to, the composition of the aviation, rail and marine transport sectors. In contrast, the ATSB has continued to experience successive reductions to its base appropriations with further reductions projected over its forward estimates. To manage these fiscal circumstances, the ATSB has reduced its core staffing profile, including specialist investigators, by approximately 25 per cent from when it was established as an independent statutory authority in July 2009.
Notwithstanding these challenges, the ATSB was able to complete a range of significant and comprehensive investigation reports during 2015–16, in addition to supporting the secondment of a number of specialist staff to the continuing search for the missing Malaysia Airlines Flight MH370 and the reopened investigation into the Norfolk Island ditching accident.
Limitations
When reflecting on the agency’s overall performance against its key deliverables and performance indicators, the ATSB has continued to meet its targets in terms of the quality and quantity of investigation reports completed and published per year. However, it is evident the ATSB has not been able to complete these reports within the published prescribed timeframes.
In relation to other key functions and broader portfolio responsibilities, the ATSB continues to maintain a capacity to record, analyse and research safety data and produce timely reports on safety trends and other research publications. Given its resource constraints, the ATSB has limited capacity to foster safety awareness, knowledge and action through safety education and has relied heavily on social media(Opens in a new tab/window) to disseminate key messages.
The ATSB has continued its transition to becoming the national rail safety investigator, as established through the Council of Australian Governments Intergovernmental Agreement on Rail Safety Regulation and Investigation Reform. In addition to the Defined Interstate Rail Network, the ATSB now has primary responsibility for investigating rail safety accidents and incidents on regional networks and metropolitan passenger networks in all states and territories other than Queensland.
Similarly, the ATSB has continued an active program of regional engagement with other transport safety agencies within the Asia Pacific region. Consistent with the approved projects and associated program funding agreements, the ATSB has undertaken a range of capacity building activities including investigator training and mentoring, policy and guidance development, and establishing compliance with international standards.
Since May 2014, at the request of the Malaysian Government, the ATSB has been leading the search operations for missing Malaysia Airlines Flight MH370, in the Southern Indian Ocean. The search for the Boeing 777 aircraft remains a major priority for the ATSB.
During the year, the operational search faced a number of significant challenges, including lost and subsequently recovered underwater electronic search equipment, medical evacuation of unwell crew and prolonged severe weather.
In December 2015, the search identified the wreck of a ship, likely to be a steel or iron vessel, dating from the turn of the 19th century. Importantly, the discovery of the shipwreck shows how the methods and technology used in the search will effectively detect and identify the missing Boeing 777 aircraft.
ATSB technical specialists also examined a number of items of aircraft debris, which were discovered on the shorelines of western Indian Ocean states. Several pieces were recovered and examined, one by the French authorities and the remainder by the ATSB. Other parts are being retrieved by the Malaysian Investigation Team for further assessment.
We continue to work with our Minister and our Malaysian and Chinese counterparts to ensure that they are kept appraised of the search progress and to enable joint decisions to be made when required.
Aviation
During the year we completed 44 aviation safety investigations and 90 short factual investigations. One significant aviation investigation involved the landing below the minima of two Boeing 737 aircraft at Mildura Airport, Victoria due to fog conditions (AO-2013-100). Both aircraft were on scheduled flights when, on nearing Adelaide Airport, fog precluded their landing.
ATSB has recommended that Airservices Australia work in collaboration with the Bureau of Meteorology to instigate a system change to reinstate the alerting function of special weather reports currently not available through an Automatic Broadcast Service.
In parallel with this occurrence investigation, the ATSB commenced a research investigation to examine the reliability of aviation weather forecasts. This research will analyse Bureau of Meteorology weather data for major Australian airports.
Other significant aviation investigations have led to improvements in the inspection method for detecting cracks in the wing attachment fittings in M18 Dromader aircraft and the removal of at-risk lateral tie rods from DH82 and DH82A Tiger Moth aircraft, with worldwide implications for this aircraft type. The ATSB also concluded its involvement as an accredited representative to the investigation by the Dutch Safety Board of the crash of Malaysia Airlines Flight MH17 in Hrabove, Ukraine on 17 July 2014.
Marine
The ATSB completed seven marine safety investigations in 2015–16. Significantly, two of the occurrences we investigated—an engine room fire on board bulk carrier Marigold and a man overboard fatality from Cape Splendor, both at Port Hedland, Western Australia—highlight the importance of investigating incidents and accidents to improve safe marine work practices.
ATSB urges the maritime industry to give heightened attention to marine work practices. As these incidents have shown, it is essential that employees implement good risk management and safety practices to prevent injury and loss of life.
Rail
During the year, the ATSB completed 19 rail safety investigations. The most significant of these involved rail collisions, derailments and a passenger fatality at Heyington Railway Station in Victoria.
As part of this investigation, we have collected and analysed over 12,000 records, categorised under the Safework Rule Procedure Breach guidelines, between June 2009 and June 2014.
Of these, approximately 15 per cent were assessed by the ATSB as being work on track-related occurrences. Preliminary analysis indicates that the majority of these occurrences can be traced to protection types being insufficient or incorrect, protection location being incorrectly positioned, protections being incorrectly removed and worksite location being incorrectly identified.
This new focus in Western Australia will result in more investigations conducted across a greater range of safety matters. It also means that the ATSB is the mandatory notification point for all Category-A occurrences within Western Australia.
We are continuing our negotiations with Queensland to complete the process of establishing a unified national system of rail safety investigation.
As the newly appointed Chief Commissioner on 1 July 2016, I am proud to lead a world-class and lean transport safety investigator. But I am keen to reshape how we commit our limited resources to improve safety for the travelling public.
We will continue investigating the majority of accidents and serious incidents involving the travelling public. This is where there is the greatest risk of loss of life and the greatest likelihood of finding significant safety issues that lead to important safety actions.
We will, however, seek to improve our efficiency by becoming more data-driven. The ATSB has one of the richest national information datasets of all safety-related occurrences in aviation as well as accidents and significant safety occurrences in the rail and marine sectors.
We use this data to identify safety trends in the aviation, rail and marine sectors but I would like to interrogate the data more actively. In so doing, we will be able to more selectively allocate our limited resources to investigating those accidents and incidents that that have the greatest potential for improving safety. If there is no obvious public safety benefit to investigating an accident, the ATSB is less likely to conduct a complex, resource-intensive investigation.
The ATSB endeavours to investigate all fatal accidents involving VH-registered powered aircraft subject to the potential transport safety learnings and resource availability. But we will need to carefully consider the resources we allocate to investigations into general aviation fatal accidents and constrain the scope of investigations into non-fatal accidents in this sector.
Safety education is key to addressing accidents and incidents that recur in general aviation. There are diminished safety benefits from investigating occurrences where there are obvious contributing factors, such as unauthorised low-level flying or flying visually into poor weather. Instead, educating pilots on the dangers of high-risk activity is where we will refocus our efforts, with an emphasis on using social media.
There are many challenges facing us in the future. Technology is already having an influence on our work. The use of remotely piloted aircraft is increasing significantly—pizza delivery by drone is reportedly imminent.
How ATSB investigates and monitors the safety of an increasing number of low-cost carriers operating within Australia will require careful consideration.
The ATSB will accumulate and interrogate its data rigorously to determine if there are indeed any systemic safety issues that affect the safety of the travelling public and others in the industry.
In the meantime, we will work with the marine, rail and aviation industries to highlight the safety concerns already identified from our occurrence data and investigation findings.
While the ATSB faces significant challenges, I am confident that the professionalism and capability of our people will ensure the ATSB remains a world-leading transport safety investigator.
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 51 of the Bulletin features ten safety investigations:
Aerial application operations encounter different risks compared to other aviation sectors because these pilots work at very low-levels. Working at these levels means that pilots encounter more hazards, such as powerlines, trees, and poles. When working at these levels, pilots have a high workload to navigate these hazards, and have a shorter reaction time if they encounter an issue and need to respond accordingly. Recent investigations by the ATSB have also highlighted the risks during an operation if the aircraft is overloaded, such as airframe damage. This is the second report in a series of publications on aerial application (including aerial spraying, spreading, and fire control). This report will cover accidents and serious incidents reported to the ATSB between May 2015 and April 2016 to coincide with the previous operational year.
What the ATSB found
Between May 2015 and April 2016, there were 29 accidents and serious incidents reported to the ATSB. Of these, 16 were accidents and 13 were serious incidents (near accidents). The most prevalent occurrence was wirestrike, comprising nearly 40 per cent of all occurrences (11 occurrences). Other types of accidents and serious incidents were engine failure or malfunction (6), collision with terrain (3), controlled flight into terrain (2), and runway excursions (2). Safety factors relating to human factors were most prevalent, in particular monitoring and checking, which contributed to 35 per cent of occurrences.
Safety message
Given the nature of these operations there are strategies to lower risks. The Aerial Application Association of Australia (AAAA) have published strategies in their pilots manual that can be applied to managing wirestrikes and engine failures. One strategy is planning. In regards to wirestrikes, planning involves knowing the location of wires in the area and organising the spraying pattern accordingly. Planning to manage the event of an engine failure includes noting potentially safe areas to land, such as open fields. Another strategy is to maintain focus during the task, such as continually reminding yourself of the presence of wires, and in the case of engine failure, focusing on following procedures will assist in avoiding further damage.
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 53 of the Bulletin features ten safety investigations:
Effective coordination and communication between airside crews could help prevent or detect mistakes that led to a collision between an Airbus A330 and aerobridge during boarding.
What happened
On 31 March 2016, an Airbus A330 was being boarded at Melbourne Airport, Victoria. Seeing that the parking brake was on, a maintenance engineer removed the main chocks early. The crews removed the nose gear chocks to dock the towbarless tractor without checking the main gear chocks. The captain, unaware that no chocks were in place, released the park brake and the aircraft rolled back, striking the aerobridge. There were no injuries and the aircraft door and aerobridge were damaged.
Why did it happen
The ATSB found that the ground and flight crew procedures were not harmonised, reducing cohesion between the crews. In the absence of clear guidance or instruction on coordinating activities during pushback, and based on incorrect assumptions, key steps involving the chocks and parking brake were performed out of sequence and without being communicated between tractor, engineering and flight crews.
: Effective coordination and communication between airside crews can prevent or detect mistakes that could otherwise lead to damage or injury. The ATSB advises organisations that work airside to ensure that ground and flight crew activities are harmonised, and to foster active communication and coordination between working crews.
Communicate and coordinate airside activities
An aircraft is attended at a terminal bay by people carrying out a wide range of concurrent tasks. Typically, they and their respective organisations work alongside many others, each operating with different processes and to varying contractual arrangements. Defining a set of processes that can apply across such varied situations and aligning them well with the other activities can be difficult. In practice, mechanical malfunctions and honest mistakes can rarely be completely eliminated. An effective procedure will include steps to ensure that activities are appropriately aligned with other procedures. One way to achieve this is to pause and check if the situation is as it should be, and to inform others of activities that could affect them.
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 52 of the Bulletin features ten safety investigations:
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 50 of the Bulletin features ten safety investigations:
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 49 of the Bulletin features ten safety investigations:
