Introduction

The Australian Transport Safety Bureau (ATSB) 2012–13 Annual Report outlines performance against the outcome and program structure in the 2012–13 Infrastructure and Transport Portfolio Budget Statements. 

Chief Commissioner’s review 2012–13

2012–13 was the ATSB’s fourth year in its current form as a fully independent agency within the Infrastructure and Transport portfolio. It has been a productive year. Our investigations yielded a range of important safety messages that touched every element of transport, from the manufacturing of vehicles through to the effectiveness of operators’ systems and the routine procedures used in the course of a working day. Especially satisfying has been the conclusion of several unusually large and complex investigations.

It was also a year in which we developed as an organisation, moving beyond the consolidation of our business systems and governance arrangements, and devoting more of our attention to enhancing our systems and capabilities. By improving and expanding these resources, the ATSB is able to bring a better perspective to bear—both on transport safety in Australia and on our own operations. We can now identify safety trends sooner, gauge the implications more thoroughly, and share our insights with the transport community more quickly and more directly.

One of the most significant improvements has been the augmentation of our enterprise system, the Safety Investigation Information Management System (SIIMS). SIIMS is an electronic management system that captures and organises information about transport accidents, tracking them from the point of notification through to the completion of investigation. The new version gives our investigators additional tools to manage their work while affording our managers greater visibility of our work on hand. This will help us to plan and manage our workloads more effectively and to gauge the implications of shifting priorities as new issues requiring investigation emerge.

We have also developed an automated event risk classification system. This will assign a risk to every aviation occurrence reported to the ATSB, based on the type of operation and type of occurrence. The event risk ratings are used in a number of ways. In 2012–13 ratings were provided twice a day to managers for every immediately reportable matter and all notable routine reportable matters in order to assist in their decisions whether to initiate investigations.

We have further developed our capability to analyse our statistical information and to identify worrying trends. We are now sharing these new insights with important stakeholders in the industry in quarterly bulletins.

Finally, while our investigators have proven themselves capable of unravelling the most complex of events (and machinery), we know that the greatest insight in the world is worthless if it is not applied. Our mission is not only to investigate safety, but to share what we have learned with the transport community. In the past year, we have worked to advance the ways in which we disseminate our message. A focus on strategic communications has helped us to improve the clarity of our investigation reports so that they can be better understood by readers without technical knowledge.

Users of smartphones and other mobile devices are now able to view our website easily, thanks to the application of advanced web technology and our use of social media. 

Aviation

The aviation investigation teams completed 43 complex and 99 short aviation accident and incident investigations during the past year. Several of these garnered considerable national and international interest. Key accomplishments included the completion of one of the largest and most complex investigations in our organisation’s history, the uncontained engine failure on a Qantas A380 over Batam Island, Indonesia, which occurred on 4 November 2010 (AO-2010-089); pursuing the issue of potentially dangerous fuel tanks in Robinson R44 helicopters; and spelling out the implications of the fatal accident involving an air ambulance rescue operation in the Budderoo National Park near Wollongong, NSW.

The completion of the Qantas A380 investigation is a matter of particular satisfaction. After the initial discovery of the fatigue-cracked oil feed stub pipe that led to the engine failure, we continued to work with the engine manufacturer, Rolls-Royce, to confirm how the manufacturing fault had occurred and how to revise their procedures to prevent recurrence. We also worked with Airbus and international regulators to highlight the implications of the accident for airframe certification standards. Our report, released on 29 June 2013, was the culmination of two and a half years of hard work and cooperation with other agencies, and spelled out issues with significant implications for air safety around the world.

The past year also saw the resolution of a different safety issue, one that tragically claimed several lives. We investigated three accidents in Australia involving post-accident fires in R44 helicopters. This led us to reinforce previous warnings to operators about the need to replace rigid aluminium fuel tanks by the deadline of 30 April 2013. As a consequence, the Civil Aviation Safety Authority (CASA) issued an Airworthiness Directive that effectively grounded any remaining R44s that had not complied by the deadline.

Another significant accident involved an air ambulance helicopter, where paramedics were winched from the aircraft to rescue an injured canyoner. During the winching, a paramedic and the canyoner fell on to some rocks and the paramedic was fatally injured. Following the investigation, the Ambulance Service of New South Wales and the helicopter operator took safety action in respect of the operating scope applied to retrieval operations and procedures used by helicopter emergency crews. In addition, paramedics, in their role as ambulance rescue crewmen, are now required to conduct annual night winching currency training.

The release of our investigation report into the ditching of the Westwind Jet at Norfolk Island that occurred on 18 November 2009 (AO-2009-072) became a subject of the ABC’s 4 Corners program and was commented upon by other media outlets. A review of the investigation by a Senate Committee was launched late in 2012. The ATSB was required to make a number of detailed submissions, provide a great many documents and attend a number of hearings at Parliament House. The enquiry report was released on 23 May 2013. The Commission has carefully considered the report and has developed an action plan in response to matters raised in the report. The Australian Government is considering its response to the Committee.

Marine

The Marine Investigation team completed 11 investigations during the year, two of which were particularly significant for safe work in and around ships. The first concerned the grounding of the general cargo ship Tycoon at Flying Fish Cove on Christmas Island (MO-2012-001). Our findings on that accident have delivered important safety messages to the managers of the port. Following this incident, the port operator commenced a program of inspections, replaced important equipment and developed a handbook and safety training.

The second accident reinforced the ATSB’s ongoing concern about the safety of stevedores and crew members on board cargo ships, an issue tragically exemplified by the death of a stevedore who was crushed by aluminium ingots on board Weaver Arrow (MO-2012-010). The accident has resulted in safety actions intended to address the handling of such cargo as well as the issue of stevedore fatigue.

We also issued a highly significant report which made important recommendations about the safety of coastal pilotage in Queensland coastal waters (MI-2010-011). This is particularly topical as Australia sees the development of port facilities and the increasing transit of shipping carrying coal and gas along these sensitive regions, including the Great Barrier Reef.

Rail

From 20 January 2013, the ATSB assumed primary responsibility for rail investigations across Australia, as part of the new national system for rail safety. This expanded national role in rail transport safety reflects the progressive implementation of the August 2011 Intergovernmental Agreement on Rail Safety Regulation and Investigation Reform. As the national system is implemented in each State, the ATSB is assuming its expanded role there as the rail safety investigator. Since January, we have worked collaboratively with our state and territory colleagues to ensure adequate resources are or will be available to respond quickly and efficiently to safety events as they occur. The Rail Investigation Team completed six complex and three short investigations during the year.

Safety priorities

Last year, for the first time, the Commission identified eight safety priorities for the coming year.  These represent major risk areas that need ongoing and heightened attention from the Australian transport community:

• General aviation pilots—General aviation (GA) pilots continue to die in accidents that are mostly avoidable. Prominent among these accidents are those that involve low flying, wirestrikes, flying visually into bad weather, mismanagement of partial power loss and poor fuel management.
• Handling approach to land—There are a worrying number of cases where stability is not adequately assessed or uncommon manoeuvres are mishandled during an aircraft’s approach to land.
• Data input errors—Human error involving incorrect data entry continues to cause concern.
  In some cases, aircraft systems and operators’ flight management procedures are not catching these errors.
• Safety around non-towered aerodromes—Non-towered aerodromes continue to pose a risk to aircraft due to poor communication between pilots, ineffective use of see-and-avoid techniques and failure to follow common traffic advisory frequency (CTAF) and other procedures.
• Robinson R44 fuel tanks—A significant number of R44 helicopters were not fitted with bladder-type fuel tanks and other modifications detailed in manufacturer’s documentation that are designed to provide for improved resistance to post-impact fuel leaks and enhanced survivability prospects in the event of an accident.
• Under-reporting of occurrences—An ATSB investigation during 2011–12 into under-reporting of wirestrikes revealed approximately 40 per cent under-reporting of incidents and accidents. While there are a range of factors that could influence under-reporting of this particular occurrence type, it is likely that there is under-reporting of other occurrences, particularly those associated with GA operations.
• Safe work on rail—The ATSB has investigated several accidents that have occurred when maintenance work was being carried out on or near railway tracks. Conducting work on or near a railway track can be dangerous if safe working rules and procedures have not been correctly implemented to protect the worksite.
• Marine work practices—The ATSB has investigated several incidents involving unsafe working practices in the maritime industry. These incidents resulted in serious injury of death following falls from heights, crush, and equipment that exploded.

Upon release of our report (MI-2010-011) into Queensland coastal pilotage in October 2012, we added this as a further risk area. In order to publicise our concerns, and educate stakeholders about what they can do to improve their own safety, we developed a communications initiative, SafetyWatch. SafetyWatch is featured on the ATSB website and forms the focus for our industry and stakeholder engagement.

Outlook for 2013–14

Last year I commented that, with 56 larger aviation investigations on hand at the end of the financial year, we had reached what I judged to be a sustainable level of activity that was allowing us to meet our targets for timely investigations while maintaining the high quality of our work. We conclude this year with 65 larger aviation investigations on hand. This higher number reflects the level of resources we had to apply to our more complex investigations and some unplanned activities such as the Senate Inquiry. It also reflects that we are not fully meeting our performance standards for delivering investigations in a timely fashion. As we report elsewhere, more work needs to be done to improve the timeliness of our investigation reporting.

Like most government agencies, we are subject to the resource constraints imposed by the government’s efficiency and savings initiatives. This, combined with our work on the implementation of the National Rail Reforms and the new responsibilities they have brought, resulted in a year in which heavy commitments meant that we had to divert resources from other investigations with consequent delays.

The ATSB has never been resourced to undertake investigations into every accident or incident that occurs. Rather, it is necessary for us to be strategic, investigating those accidents and incidents that are likely to yield safety improvements for transport operators and the travelling public.

We can expect to continue to work in a resource-constrained environment during the foreseeable future and will need to be creative in finding ways to deliver the high quality expected by the government and the Australian public. Our responsibilities have grown in the rail sector and we are also acutely conscious of the effect on our available resources of the demands of one or more complex investigations.

More than ever we will need to be selective in deciding what matters to investigate in order to achieve the greatest value and confidence for the travelling public. Under current and forecast resource limits, a time is approaching when we will have to be more constrained as to which investigations and activities we can undertake and as to the extent of those investigations we do undertake. While we will continue to take all possible steps to mitigate it, the risk that we will miss an important issue increases as our resources diminish.

We continue to remain alert and prepared to handle a major accident in aviation, marine or rail and recognise the exceptional effort that would be required to respond. To ensure that we remain alert and responsive, our staff members continue to participate in planning and exercises and we continue to learn from our overseas counterparts.

We also continue to work with our neighbours in the region and to be an active and constructive player in the International Civil Aviation Organization, the International Maritime Organization and other international forums that have a role in transport safety. I am pleased that we have been able to assist our neighbours in the region during the year, using development cooperation funding from AusAID.

While the times are challenging, I remain enormously proud of the dedication and the accomplishments of our investigators and other staff. The technical knowledge and expertise within the ATSB is world-class. I thank the investigation and supporting staff of the ATSB whose efforts and expertise consistently enable us to provide an essential service to the Australian travelling public.

Martin Dolan
Chief Commissioner/CEO 

• Download:
  ATSB Annual Report 2012-13 (5.03 MB)

Why have we done this report

Significant debate has occurred within the aviation industry regarding the issues of pilot training and experience, particularly with regard to the introduction of new pilot training programs that are focused on training cadet pilots. The main concern being presented by some sectors of the industry that are not in favour of these concepts is that these low-hour co-pilots are not as competent as their high-hour peers.

The ATSB gathered data from three airlines to explore the issue of pilot performance as a function of both flight hour experience, and entry pathway. Entry pathway analysis compared cadet pilots (who generally had not accumulated prior flight hours or experience) to those pilots who entered an airline after accumulating flight hours in other areas of the aviation industry.

Data were collected on a number of metrics from simulator check flights, which covered non-normal operations, and line checks, which covered normal day-to-day flight operations.

What the ATSB found

The overall performance of cadets and low-hour pilots matched that of their direct entry and high-hour peers. All pilots were marked as proficient at the completion of the check flights, with the only differences between the groups being a function of how many exceeded the required standard.

The differences between the low and high-hour pilots in ‘meeting’ and ‘exceeding’ the standard across all metrics were variable within airlines and inconsistent across all three airlines. This suggests that the differences between the groups were not of a systemic nature that would highlight an area of concern for industry. While the metric normal landing showed a difference across two of the three airlines, none of the other required regulatory manoeuvres or technical metrics were significantly different in more than one airline. For non-technical metrics, both leadership and situation awareness were significantly different in all three airlines. Although this is understandable given the low experience of cadet and low-hour pilots, focused exposure to those metrics during initial airline training may reduce this difference as was seen in the data for cadets collected at the 5-year mark in one airline.

Safety message

The evidence in this report indicates that the cadet pathway for low-hour pilots is a valid option for airlines. There was no evidence to indicate that cadets or low-hour pilots within the airlines studied were any less competent or proficient than their direct entry and high-hour peers.

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 22 of the Bulletin features 11 safety investigations:

Turboprop aircraft

• Left main landing gear collapse involving a Raytheon B200, VH-ZCO
• Aircraft proximity event between a Fairchild SA227, VH-HVH and an Aerospatiale AS350, VH-JRJ

Piston aircraft

• Aircraft proximity event between two Cessna 172s, VH-EOE and VH-LWX
• Aircraft proximity event between a Piper PA-28, VH-TXH and a Cessna 172S, VH-EWX
• Operation below minimum safe altitude involving Aero Commander, VH-TQA
• TCAS warning between a Cessna 310R, VH-AEY and a Fokker F28-100, VH-FKJ
• Runway incursion involving a Piper PA-31, VH-KLS and a vehicle
• Total power loss involving a Mooney M20J, VH-NFP
• Aircraft proximity event between a Cessna 172, VH-WYG and a Cessna 185, VH-OZX

Helicopters

• Collision with terrain involving a Bell 412, VH-EMZ
• Aircraft proximity event between a Janus glider, VH-IZI and a McDonnell Douglas 500N, VH-KXS

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 20 of the Bulletin features ten safety investigations:

Turboprop aircraft

• Weight and balance event involving Fairchild SA-227AC, VH-UUO

Piston aircraft

• Landing gear separation involving Piper PA28, VH-JXR
• Wheels up landing involving Cessna 210M, VH-PBV
• Collision with terrain involving Grob G-115, VH-ZTM
• Aircraft proximity event between a Piper PA-44, VH-TYS and a Cessna 172S, VH-EUH
• Landing gear collapse involving Piper PA-30, VH-HPR
• Wheels up landing involving Piper PA-24-260, VH-DRB
• Weather related precautionary landing involving a Piper a PA-28, VH-MSG

Helicopters

• Collision with terrain, involving AS350, VH-EWM
• Wirestrike involving Enstrom 480B, VH-VDC

Why the ATSB did this research

Emergency locator transmitters are radio beacons carried on most aircraft so that in the event of an accident in a remote location the aircraft wreckage and its occupants can be located quickly by search and rescue (SAR) operations. Finding the aircraft wreckage quickly not only increases the chance of survival of the occupants, but also reduces the risk to pilots of SAR aircraft who commonly need to operate in marginal weather conditions and over mountainous terrain.

Airframe mounted emergency locator transmitters (ELTs) are designed to automatically activate following an impact typical of a collision. However, the effectiveness of airframe ELTs in aviation accidents has been questioned for some time by accident investigation agencies and by the aviation community. Beyond individual examples of ELTs not activating following an accident, there has been little research done to date to review how reliably ELTs operate as designed after an aircraft accident. In this research investigation, the ATSB identifies safety concerns regarding the operation of ELTs and presents data on the effectiveness of ELTs activating following an accident.

What the ATSB found

Data from the ATSB database show that ELTs function as intended in about 40 to 60 per cent of accidents in which their activation was expected.

Records of the Australian Maritime Safety Authority’s SAR incidents shows that search and rescue personnel were alerted to aviation emergencies in a variety of ways including radio calls and phone calls, and that ELT activation accounted for the first notification in only about 15 per cent of incidents. However, these ELT activations have been directly responsible for saving an average of four lives per year.

In accidents where ELTs did not work effectively (or at all) it was found that their performance could be affected by:

• not selecting the ELT activation to armed before flight
• incorrect installation
• flat batteries
• lack of water proofing
• lack of fire protection
• disconnection of the co-axial antenna cable from the unit during impact
• damage and/or removal of the antenna during impact
• an aircraft coming to rest inverted after impact.

Safety message

Pilots and operators of general aviation and low-capacity aircraft need to be aware that a fixed fuselage mounted ELT cannot be relied upon to function in the types of accidents in which they were intended to be useful. The effectiveness of ELTs in increasing occupant safety and assisting SAR efforts may be enhanced by using a GPS-enabled ELT, using an ELT with a newer 3-axis g-switch, ensuring it is installed correctly, ensuring your beacon is registered with AMSA and pre-emptively activating the beacon if a forced landing or ditching is imminent. Additionally, carrying a personal locator beacon (PLB) in place of or as well as a fixed ELT will most likely only be beneficial to safety if it is carried on the person, rather than being fixed or stowed elsewhere in the aircraft.

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

• Radio failure involving a Mitsubishi MU-2B, N64MD
• Airspace related event between Bombardier DHC-8-402, VH-QOB and Robinson R22, VH-HLY

Piston aircraft

• ATC procedural error involving a Piper PA-34, VH-FEJ
• Aircraft proximity event between a Kawasaki BK117, VH-CSG and a Cessna 404, VH-XDA
• Nose landing gear malfunction involving a Hawker Beechcraft B58, VH-OMS
• Aircraft proximity event between Piper Chieftain, VH-EDV and Cessna 172 Hawk XP, VH-JQQ
• Aircraft proximity event between a Mooney M20, VH-FRO and a Piper PA-31, VH-HJE
• Two airspace related events at Nagambie (ALA)
• Collision with terrain involving a Pietenpol Air Camper, VH-ARW

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

• Significant wind change during take-off involving Boeing 737, VH-VZL 

Turboprop aircraft

• Aircraft proximity event between a Piper PA-28, VH-PZK and a Cessna 441, VH-VEJ
• Aircraft proximity event between a Beech B200C, VH-AMQ and a Ventus glider, PH-1234
• Aircraft proximity event between a Beech B200C, VH-VAE and an unidentified glider
• Wirestrike involving an Ayres Thrush S2R-T34, VH-HAH

Piston aircraft

• Power loss (both engines) involving Piper PA-39, VH-RMA
• Aircraft proximity event between a Piper PA-44, VH-MHZ and a Hawker G36, VH-JKL
• Engine failure involving a Cessna 182R, VH-OWZ
• Wheels up landing involving a Cessna 337F, VH-JUP

Helicopters

• Loss of control involving Robinson R22, VH-HGI

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

• Wake turbulence event involving a Boeing 737, VH‑YIO
• Windshield cracking event involving a Cessna Aircraft 750, VH-RCA 

Turboprop aircraft

• Airspace related event involving Beech 1900C, VH-KFN and Aerospatiale AS350 B2, VH-VRW
• Runway loss of separation between Bombardier DHC-8, VH-ZZJ and Aerospatiale, VH-LOJ
• Pilot incapacitation event involving a Hawker B200, VH-FDT

Piston aircraft

• Loss of separation involving a Cessna 310, VH XXT and a Cessna 210, VH RQD
• Engine failure involving Cirrus SR22, VH-WYH
• Loss of performance involving DH-82A (Tiger Moth), VH-DDA
• Aircraft proximity event between an Alpha Aviation R2160, VH-NZT and a Diamond DA 40, VH-UNH

Helicopters

• Loss of control involving a Robinson R44, VH-RYO

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.