Aviation Short Investigation Bulletin - Issue 21

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.

The investigations Issue 21 of the Bulletin features nine safety investigations:

Turboprop aircraft

Piston aircraft

Publication details

Investigation number AB-2013-177
Series number 21
Publication type Aviation Short Investigation Bulletin
Publication mode Aviation
Publication date 07/08/2013
Subject matter Aviation Bulletin

Aviation Short Investigation Bulletin - Issue 18

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.

The Aviation Short Investigation Bulletin, Issue 18 features 10 safety investigations:

Jet aircraft

Turboprop aircraft

Piston aircraft

Helicopters

Publication details

Investigation number AB-2013-070
Series number 18
Publication type Aviation Short Investigation Bulletin
Publication mode Aviation
Publication date 17/05/2013
Subject matter Aviation Bulletin

Aviation Short Investigation Bulletin - Issue 17

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.

The Aviation Short Investigation Bulletin, Issue 17 features 10 safety investigations:

Jet aircraft

Turboprop aircraft

Piston aircraft

Helicopters

Publication details

Investigation number AB-2013-050
Series number 17
Publication type Aviation Short Investigation Bulletin
Publication mode Aviation
Publication date 23/04/2013
Subject matter Aviation Bulletin

Identifying risks in transport: Safety issues from ATSB occurrence investigations, July 2009 to June 2012

Why is the ATSB doing this research?

Each year, the ATSB conducts investigations into transport safety matters in aviation, rail and marine. Most of these reports document safety issues (factors that have a potential to adversely affect the safety of future operations) identified during the investigation, along with the assigned risk level for each safety issue. The ATSB also individually documents safety actions completed by industry or regulators in response to the identified safety issues. When no or inadequate safety action occurs, the ATSB may also release a safety recommendation, which is required to be responded to within 90 days.

This report documents the ATSB identified safety issues and related safety actions and recommendations for the 2011–12 financial year and trends across 3 financial years. It will explore the risk levels assigned and provide an understanding of where the greatest risks to each transport sector appears to lie, based on investigation findings. The results will be useful for government decision makers, regulators and the aviation, rail and marine industries to understand if and where attention to risk needs to be applied.

What the ATSB found

In the 2011–12 financial year, the ATSB completed 56 occurrence investigations into air transport, general aviation, rail and marine accidents and incidents. These investigations identified 100 safety issues, of which 28 posed a significant risk to safe ongoing operations and required safety action. More significant issues were identified in marine operations than in any other transport sector. Most safety issues were addressed with safety actions, especially those taken proactively by industry (more than 90 per cent of all safety actions).

The types of safety issues identified in investigations completed in 2011–12 were similar to those found in previous financial years, though there were more issues relating to marine operations, and less relating to general aviation. Safety issues were most often found with risk controls, particularly procedures. Safety management processes of organisations were an emerging issue in marine accidents and incidents in 2011–12, as were on-vehicle safety procedures and equipment in rail.

In all transport sectors, the most commonly identified safety factors that contributed to the accident or incident were the actions of individuals. In aviation, aircraft operation actions usually contributed to accidents and incidents – in marine, navigation and deck operation actions, and in rail operations, maintenance and vehicle operation actions most commonly contributed. Effects of local conditions (such as weather, training and skill level, workload, stress or fatigue) were common contributors to accidents and incidents.

Safety message

The ATSB plays a central role in identifying where areas of safety concern exist in Australia’s transport system. While investigations tend to show that individual actions contribute to most accidents and incidents, there are many latent safety issues that have the potential to cause further accidents if not addressed. Issues with training, fatigue, operating procedures, and the quality of safety management systems frequently contribute to accidents, and are wholly avoidable.

The ATSB continues to promote safety actions initiated by industry as the most timely and effective way to drive safety improvements to close identified gaps in safety. The misfortunes of others are a timely reminder to everyone involved in transport to look for similar safety risks in their operation that could lead to a similar accident or serious incident.

Publication details

Investigation number XR-2012-001
Publication type Research and Analysis Report
Publication mode Corporate
Publication date 25/03/2013
ISBN 978-1-74251-314-0

Avoidable Accidents No. 6: Experience won't always save you

Introduction

As pilots, we are familiar with well-publicised events of aircrew who, as a result of their experience and exceptional airmanship, avoided what could have been a disaster and a tragic loss of life. Pilots, such as Captain ‘Al’ Haynes in command of a United Airlines Douglas DC-10 on a flight from Denver to Chicago in July 1989, that had the fan wheel of its number two (centre) engine disintegrate, causing a loss of all three of its hydraulic control systems — an unprecedented problem that made the aircraft nearly impossible to fly or land. Captain Haynes and his crew figured out how to gain some control of the plane and were eventually able to get the severely disabled airliner to the Sioux City, Iowa airport, where they crash-landed. The aircraft broke apart during the landing and although there were 112 fatalities, a remarkable 185 people survived the crash.

More recent events, such as the US Airways Airbus A320 under the command of Captain Chesley Sullenberger, an experienced pilot, who together with his co-pilot, successfully ditched their stricken aircraft in the Hudson River after both its engines lost power following multiple bird ingestion on take-off from New York’s La Guardia airport in January 2009. All the passengers and crew were rescued from the floating aircraft without injury. Then there was the effort of Captain Richard de Crespigny and his crew after the Qantas Airbus A380 they were flying experienced an uncontained engine failure just after departing Singapore’s Changi airport in November 2010. They guided the heavily damaged aircraft back to a safe landing at Singapore, averting what could have been a major catastrophe.

There have been many other individual acts of outstanding airmanship where ‘experience’ clearly played a part in the safe outcome. At the same time, a closer analysis of events suggests that things other than experience alone had a hand in the outcome. Good training, focussed preparation, a readiness for the unexpected and good crew interaction also had a significant part to play. Unfortunately, those other factors go mostly unreported in our media and the impression is created that mostly it is an individual’s experience that makes the difference.

In the same way, in those tragic cases where the outcome was a fatal accident, many factors were in play. Naturally, media interest in an accident is heightened when it involves an experienced pilot who is also a well-known aviation identity. Although this adds a human interest aspect to the tragedy, the subsequent media reports often do little to assist a thorough understanding of the circumstances that led to the accident.

The following selection of occurrences, taken from the Australian Transport Safety Bureau (ATSB) archives1 over the previous 20 years, bears testimony to the fact that experience alone is not necessarily a protection against vulnerability to an accident. 

Key messages

Fatal accidents can and do happen to experienced pilots, as the following examples illustrate. In some of these occurrences, very experienced pilots were undertaking flying that involved much higher risk, and as a consequence found that, in those circumstances, their flying experience alone, was unable to help them avoid disaster. Other accidents involved experienced pilots who may have allowed factors other than their experience to influence their actions. Yet in other accidents, the pilot’s vast experience may have even led to decisions that, in hindsight, were associated with more risk than necessary.

The report provides some insight as to why experience alone will not always prevent a pilot from having an accident and provides awareness of the following.

  • Experience alone can never compensate for high-risk activity.
  • Sound decision-making and experience are not necessarily synonymous.
  • Using pilot experience as mitigation for potential operational risks is inadvisable. If the risks are unacceptable for a qualified and competent pilot, there should be no reason for an experienced pilot to find it otherwise.
  • Attend to the three Cs — compliance, communication and complacency, and all the other human performance considerations. Experience cannot overcome the mental and physical limitations of humans. 

Conclusion

‘Human beings, who are almost unique in having the ability to learn from the experience of others, are also remarkable for their apparent disinclination to do so.’ 

Experience, used wisely, can be extremely useful for avoiding accidents and invaluable in an emergency. Experience also allows a pilot in normal operation to anticipate events, allowing more time to review and monitor a flight without having to ‘sweat’ the details. However, as can be seen, experience does not give a pilot immunity from an accident.

Experienced pilots will no doubt be familiar with many of the events discussed in this report and should not assume they are any less vulnerable than the pilots involved in the accidents reported on these pages. Less experienced pilots can learn to avoid the pitfalls that can develop with their increasing experience. A pilot, no matter what level of experience, should never be beyond learning from the experiences of others. 

Publication details

Publication number AR-2012-035
Investigation number AR-2012-035
Publication type Avoidable accidents
Publication mode Aviation
Publication date 26/02/2013
ISBN 978-1-74251-291-4

Australian Shipping Occurrence Statistics 2005 to 2012

Why did we do this report

The ATSB receives reports on accidents and other safety incidents involving Australian registered trading vessels (cargo and/or passengers) around the world and trading vessels flying foreign flags within Australia’s maritime jurisdictions. The aim of this report is to provide participants in the shipping industry and other interested parties with information on what accidents and incidents have happened, how often they have happened, and what can be learnt from them.

What the ATSB found

In 2012, there were 154 marine safety occurrences reported to the Australian Transport Safety Bureau. This was over 50 per cent higher than the 2005-12 average of 100 occurrences each year. The increase in occurrences in 2012 was due to substantial increases in the number of reported ‘incidents’ (137) and ‘serious incidents’ (12). Fewer than 10 accidents were reported each year between 2005 and 2012, with five in 2012.

Between 2005 and 2012, there were 245 people killed, missing or seriously injured from reported marine occurrences. In 2012 there were 6 deaths and 33 serious injuries; the latter was the highest number for any year of the report period.

Bulk carriers and cargo vessels (including container, roll-on – roll-off cargo, heavy lift and livestock ships) have been the most common vessels involved in occurrences since 2005 and their involvement increased substantially in 2012. There were also increases in the involvement of tankers, offshore support vessels and tugs.

The number of foreign vessels involved in occurrences grew considerably in 2012. This was predominantly due to an increased involvement in incidents (up 55 per cent on 2011), but there were also more foreign registered vessels involved in serious incidents.

The number of Australian registered vessels involved in occurrences also increased in 2012 and the highest number of occurrences recorded was by Australian, Panamanian and Singaporean registered vessels.

Between 2005 and 2012, the most common types of occurrence were damage to the ship or equipment, serious injury and equipment failure. In 2012, there were increases in five of the six most common occurrence types, with serious injury, equipment failure and machinery failure reaching their highest levels for any year of the 2005-2012 period.

Safety message

Marine occurrence statistics provide a reminder to everyone involved in shipping that accidents, incidents, and injuries happen more often than is widely believed. Some of the most frequent accident types are preventable, particularly fatalities to crew and shipboard workers. Operators should learn from the experiences of others in the industry to help identify the safety risks in their operation that could lead to a similar accident or serious incident.

Thorough reporting of safety incidents is paramount. Analysis of reported occurrences helps to understand why accidents and incidents happen, and where the major safety risks are. This helps everyone in the marine industry to better manage their safety risk.

Publication details

Investigation number MR-2013-002
Publication type Statistical Publication
Publication mode Marine
Publication date 24/04/2013
Subject matter Rail statistics

Aviation Short Investigation Bulletin - Issue 16

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.

The Aviation Short Investigation Bulletin, Issue 16 features 10 safety investigations:

Turboprop aircraft

Piston aircraft

Helicopters

Unmanned aerial systems

Publication details

Investigation number AB-2013-028
Series number Issue 16
Publication type Aviation Short Investigation Bulletin
Publication mode Aviation
Publication date 21/03/2013
Subject matter Aviation Bulletin

Aviation Short Investigation Bulletin - Issue 14

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.

The Aviation Short Investigation Bulletin, Issue 14 features 11 safety investigations:

Turboprop aircraft

Piston aircraft

Helicopters

Publication details

Investigation number AB-2012-157
Publication type Aviation Short Investigation Bulletin
Publication mode Aviation
Publication date 20/12/2012
Subject matter Aviation Bulletin

A systematic review of the effectiveness of safety management systems

Why have we done this report?

Australian aviation, marine and rail industries have all recently incorporated safety management systems into regulations and operations as a required way of managing safety. Safety management systems (SMS) refer to organisations having a systematic approach to managing safety, including organisational structures, accountabilities, policies and procedures. They generally include several common elements such as explicit management commitment to safety, appointment of key safety personnel, hazard identification and risk mitigation, safety investigations and audit, and safety performance monitoring. Although Australia’s transport industries’ SMS approach is following world’s-best practice, little empirical research evidence has been presented to determine the impact on safety of a structured SMS. The objective of this research investigation was to examine the published research literature into the efficacy of safety management systems, safety programs and related management processes that is applicable to high-reliability transport operations. The examination also aimed to identify which characteristics of these systems, and/or other organisational characteristics or external influences, are most related to the quality of an organisation’s safety management. The outcome of this review may help organisations and regulators prioritise their efforts on those areas most likely to improve safety performance, and provide guidance for reviewing, auditing or investigating an organisation’s safety management processes.

What was found

A comprehensive search of the literature found 2,009 articles, with 37 directly relevant to the objectives of this investigation, and a significant amount of literature published in the past 5 years. However, only 14 involved an SMS designed to avoid low-probability/high-consequence (LP-HC) accidents, with the remaining 23 studies relating to work health and safety. In addition, very few of these studies were undertaken in transport domains, and many studies only measured subjective perceptions of safety rather than objective measures. The limited quality empirical evidence available relate to the difficulty of measuring objective safety improvements in industries where the SMS is aimed at avoiding LP-HC accidents and the relative recency of the application of SMS.

Nineteen studies analysed objective metrics such as safety performance, employee behaviours, and accidents. Several of these found that organisations with a certified SMS had significantly lower accident rates. However, across these studies, there was a lack of agreement about which components of a safety management system individually contributed the most to safety performance.

A further 18 studies used self-report metrics about perceptions of safety within the organisation to examine the effectiveness of an SMS. Although there was also a general lack of consistency across which elements of an SMS affected safety the most, it was commonly found that both management commitment and safety communication were important.

Safety message

Incorporating safety management systems into normal business operations does appear to reduce accidents and improve safety in high-risk industries. At present, there have only been a small number of quality empirical evaluations of SMSs, and it is unclear as to whether any individual elements of a SMS have a stronger influence on safety over other elements, although management commitment and appropriate safety communications do affect attitudes to safety. Transport organisations that provide an appropriate investment and commitment to a safety management system should receive a positive return on safety.

Publication details

Investigation number XR-2011-002
Publication type Research and Analysis Report
Publication mode Corporate
Publication date 10/12/2012
Authors Dr Matthew J W Thomas | Westwood-Thomas Associates
ISBN 978-1-74251-303-4
Subject matter Human factors

Aviation Short Investigation Bulletin - Issue 15

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.

The Aviation Short Investigation Bulletin, Issue 15 features nine safety investigations:

Turboprop aircraft

Piston aircraft

Helicopters

Publication details

Investigation number AB-2013-018
Series number Issue 15
Publication type Aviation Short Investigation Bulletin
Publication mode Aviation
Publication date 27/02/2013
Subject matter Aviation Bulletin