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

Why have we done this report

In the last three decades, Australia has seen a significant growth in the number of amateur-built aeroplanes (aircraft built for personal use from an original design, established plans or kit, which are not entirely built and assembled in a factory).  However, the safety record of amateur-built aircraft in Australia had not been robustly established.

What did this report do

The ATSB investigated the safety history of amateur-built aircraft in Australia through analysis of accident data held in the ATSB’s occurrence database from 1988 to 2010. Comparisons were made between accidents involving amateur-built aircraft and those involving similar factory-built aircraft to help identify whether the rate and types of accidents differed between these two groups of aircraft.

What the ATSB found

Amateur-built aircraft had an accident rate three times higher than comparable factory-built certified aircraft conducting similar flight operations between 1988 and 2010. The fatal and serious injury accident rate was over five times higher in amateur-built aircraft, in particular due to relatively more serious injury accidents.

The pilots of amateur-built aircraft involved in accidents were significantly more experienced overall than factory-built aircraft accident pilots. However, they were significantly less experienced on the aircraft type that they were flying at the time of the accident.

Over half of the accidents were precipitated by mechanical events, which were mainly complete or partial engine failures. Following the amateur-built phase one test period, mechanical failures were still significantly more common when compared with factory-built aircraft. A quarter of accidents were from loss of aircraft control. Structural failures were not common precursors in amateur-built aircraft.

Collision with terrain and forced landing accidents were more frequent in amateur-built aircraft. Collisions with terrain, hard landings, and runway excursions were more likely to result in a serious injury from an amateur-built aircraft accident than for factory-built accidents.

Safety message

Builders of amateur-built aircraft should select, install and maintain aircraft engines carefully as engine issues are the most likely reason why an accident will occur. Careful consideration to occupant protection at the time of building is also encouraged as serious injuries have been disproportionally more common.

Owners of amateur-built aircraft should ensure they have adequate training in the same type of aircraft before operating the aircraft they have built, or purchased second-hand.

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.

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.

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

• TCAS advisory involving Bombardier DHC-8-315, VH-SBG
• Airspace related event involving Kingair, VH-VAH and Ag-Cat, VH-IFE

Piston aircraft

• Runway excursion involving Cessna 210N, VH-WPD
• Aircraft proximity event involving a Cessna 172S, VH-VMM and a Schweizer 269C-1, VH-FTR
• Collision with terrain involving Cessna 172N, VH-JGR
• Aircraft proximity event between two Piper PA-28 aircraft, VH-LXH and VH-TAU
• Runway excursion involving Cessna T210, VH-DQI

Helicopters

• Hard landing involving Robinson R44 VH-HYR
• Loss of control involving Robinson R22, VH-HTD

Unmanned aerial systems

• Airspace incursion involving unmanned airship, Airship 11

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

• Propeller strike involving Fairchild SA227-DC, VH-WBQ (AO-2012-106)
• Depressurisation event involving a Metro 3, VH-SEF (AO-2012-127)

Piston aircraft

• Two aircraft proximity events at Ballarat airport (AO-2012-102)
• Inadvertent landing gear retraction involving Aero Commander, VH-YJS (AO-2012-110)
• Airspace related event between Cessna 172, VH-EPB and Piper Warrior, VH-BZE (AO-2012-111)
• Fuel starvation involving Piper Seneca, VH-BTW (AO-2012-112)
• Runway excursion involving Piper PA-28, VH-SFK (AO-2012-113)
• Engine failure involving Piper PA-32, VH-FAJ (AO-2012-125)
• Hard landing involving Cessna P206B, VH-EGG (AO-2012-135)

Helicopters

• In-flight fire involving Eurocopter AS-350BA, VH-HEB (AO-2012-084)
• Collision with terrain involving Kawasaki 369HS, VH-JWJ (AO-2012-104)