Aviation Short Investigations Bulletin - Issue 48

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 48 of the Bulletin features ten safety investigations:

Turboprop aircraft

Piston aircraft

Helicopters

Hot Air Balloons

Publication details

Investigation number AB-2016-044
Series number 48
Publication type Aviation Short Investigation Bulletin
Publication mode Aviation
Publication date 27/05/2016
Subject matter Aviation Bulletin

The effect of Australian aviation weather forecasts on aircraft operations:Adelaide and Mildura Airports, Australia

Why did the ATSB do this research

A number of unforecast weather episodes relating to flights into major Australian airports have led to unforeseen diversions, holding, and in some cases, landing below published safe limits. For example, on 18 June 2013, two flights encountered unforecast weather en route to Adelaide, South Australia, leading to a diversion to Mildura Airport, Victoria. Upon arrival, both encountered weather unsuitable for landing.

Aerodrome weather forecasts allow pilots and operators to develop a contingency plan during flight planning and en route (such as carrying additional fuel for holding or diversion) when there are indications of conditions potentially unsuitable for landing at the intended destination. Weather unsuitable for landing mostly involves thunderstorms, a low cloud base and/or low visibility, and to a lesser extent, strong winds.

This is the first report in a series covering Australian airports supporting regular passenger transport operations. The results will assist aircraft operators to focus on the highest risk seasons and times of day for weather reliability, facilitating better flight planning and support for pilots. They will also allow for more informed prioritisation of investment decisions about aircraft and aerodrome navigational equipment. This report focuses on Adelaide and Mildura Airports.

What the ATSB found

Weather conditions were reported as unsuitable for landing in about one in every 22 days at Adelaide Airport and one in 10 days at Mildura Airport. Considering the total time, episodes of weather below the landing minima were rare, accounting for only 0.23 per cent of the time at Adelaide and 0.99 per cent at Mildura.

It was very rare for forecasts not to provide sufficient indication of conditions unsuitable for landing (less than 0.1 per cent of all time). However, when weather conditions were unsuitable for landing, aerodrome forecasts (TAFs) did not provide sufficient indication of these conditions 13 per cent (Adelaide) and 9 per cent (Mildura) of that time. At Adelaide, using the shorter-term trend forecasts (TTF) alone, unsuitable conditions were not indicated 22 per cent of that time.

Taking into account aircraft traffic arrival patterns, an average of 15 (Adelaide) and four (Mildura) aircraft were expected to arrive during unforecast weather each year by these TAFs. For TTFs used alone at Adelaide, 27 aircraft were expected to be affected per year. Mornings had the most aircraft arrivals affected by unforecast weather, especially in June (Adelaide) or July (Mildura).

The potential impact on safety, measured by unexpected holding time required if a flight crew was unable to land due to unforecast weather varied considerably. Unexpected holding periods of 30 minutes or more were calculated in Adelaide mornings 53 per cent of the time when unsuitable conditions were not indicated by the TTF. For TAFs, this was 36 per cent of the time for Adelaide mornings, and 64 per cent of the time for Mildura mornings.

Retrieving the TAF closer to the intended landing time led to a lower incidence of insufficient indications of weather conditions that were unsuitable for landing, particular in the mornings. At Adelaide in the mornings, an increase of 2.3 aircraft arrivals per year were predicted during unexpected unsuitable conditions for every additional hour prior to arrival that a TAF is retrieved.

Safety message

In the morning at Adelaide and Mildura, it is relatively more important that forecasts are retrieved at the latest possible time (before the point where a diversion is no longer possible) prior to arrival. Using the alternate minima rather than landing minima for all decision making, both for pre-flight planning and in-flight, considerably improves the chances of not being exposed to unexpected unsuitable conditions for landing.

Publication details

Investigation number AR-2013-200
Publication type Research and Analysis Report
Publication mode Aviation
Publication date 10/07/2017

Emerging trends in Australian aviation safety January – June 2015

When aviation safety incidents and accidents happen, they are reported to the ATSB. The most serious of these are investigated, but most reports are used to help the ATSB build a picture of how prevalent certain types of occurrences are in different types of aviation operations.

The ATSB uses this data to proactively look for emerging safety trends. By monitoring trends, issues of concern can be communicated and action taken to prevent accidents.

Proactive trend monitoring is a data-driven process, reviewing all occurrences to see if there are subtle changes that may point to a larger issue. Potential issues are then monitored by the ATSB, and shared with industry and other government agencies. Safety actions can then be taken by the most appropriate people to prevent these issues resulting in accidents. These trends can also point to the need for the ATSB to target particular types of occurrences for investigation.

This report summarises significant trends in Australian aviation from January to June 2015, and resultant safety action being taken to address these trends.

Publication details

Investigation number AR-2016-002
Publication type Statistical Publication
Publication mode Aviation
Publication date 11/05/2016

Aviation Short Investigations Bulletin - Issue 47

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

Piston aircraft

Helicopters

Separation issues

Publication details

Investigation number AB-2016-014
Series number 47
Publication type Aviation Short Investigation Bulletin
Publication mode Aviation
Publication date 13/04/2016
Subject matter Aviation Bulletin

Engine failures and malfunctions in light aeroplanes 2009 - 2014

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.

Publication details

Investigation number AR-2013-107
Publication type Research and Analysis Report
Publication mode Aviation
Publication date 09/03/2016

Pilot incapacitation occurrences 2010–2014

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.

Publication details

Investigation number AR-2015-096
Publication type Safety Education Material
Publication mode Aviation
Publication date 18/02/2016

Aviation Short Investigations Bulletin - Issue 45

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

Turboprop aircraft

Piston aircraft

Helicopters

Remotely piloted aircraft systems

Publication details

Investigation number AB-2015-135
Series number 45
Publication type Aviation Short Investigation Bulletin
Publication mode Aviation
Publication date 22/12/2015
Subject matter Aviation Bulletin

Aviation Occurrence Statistics: 2005 to 2014

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

Publication details

Investigation number AR-2015-082
Publication type Statistical Publication
Publication mode Aviation
Publication date 23/12/2015
Subject matter Aviation statistics

Aviation Short Investigations Bulletin - Issue 46

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

Turboprop aircraft

Piston aircraft

Helicopters

Publication details

Investigation number AB-2015-148
Series number 46
Publication type Aviation Short Investigation Bulletin
Publication mode Aviation
Publication date 28/01/2016
Subject matter Aviation Bulletin

Aviation Short Investigations Bulletin - Issue 44

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

Helicopters

Publication details

Investigation number AB-2015-118
Series number 44
Publication type Aviation Short Investigation Bulletin
Publication mode Aviation
Publication date 04/11/2015
Subject matter Aviation Bulletin