This report tables rail safety occurrence data by state and territory between 1 January 2001 and 31 December 2009. Data is adjusted biannually to reflect new information that comes to light during the reporting period. There is a lag period of approximately 3 to 4 months between the end of the 6-monthly reporting period and publication of this data. The data is presented as counts, and normalised using kilometres travelled and number of track kilometres. Data presented in this report conforms to ON-S1: Occurrence Notification Standard 1 (2004) and OC-G1: Occurrence Classification Guideline 1 (2008). This report excludes tram and light rail or monorail operations.

Each year, 'responsible persons', as defined in the Transport Safety Investigation Regulations 2003, Part 2.5, provide the Australian Transport Safety Bureau (ATSB) with reports on aviation accidents and incidents, collectively termed occurrences. These reports are used by the ATSB to assist with the independent investigation of occurrences and for identifying safety trends.

This report provides aviation occurrence data for the period 1 January 1999 to 31 December 2009. The data contained herein is dynamic and subject to change pending the provision of new information to the ATSB. The data will be adjusted biannually to reflect new information received during the reporting
period.

For commercial air transport (high-capacity regular public transport (RPT), low-capacity RPT and charter), although the accident rate had climbed in 2007 and 2008, the number of accidents reduced from 29 (2008) to 11 in 2009. This accident trend was mostly driven by changes in the accident rate for charter operations. Similarly, the number of serious incidents for commercial air transport reduced from 45 (2007 and 2008) to 26 in 2009. There were no fatal air transport accidents in 2009. One significant accident in 2009 involved the tail scrape and runway excursion at take-off of a foreign-registered Airbus A340-500 in Melbourne on 20 March. Charter has an accident rate that is about five times that of low-capacity and high-capacity RPT. Most fatal accidents in commercial air transport are in charter operations, and it has a similar rate of fatal accidents to all general aviation.

For general aviation (aerial work, flying training, and private/business and (VH-registered) sport aviation), accidents and serious incidents have remained generally consistent since 2007. In 2009, there were 126 accidents, including 18 fatal accidents, and 95 serious incidents. Compared with flying training, aerial work has an accident rate per million hours that is two times higher, and private/business has an accident rate that is 2.5 times higher. In terms of fatal accidents per million hours, the fatality rate in aerial work is three times higher than flying training, and private/business is at least six times higher.

Summary

The ATSB receives around 15,000 notifications of aviation occurrences each year; 8,000 of which are accidents, serious incidents and incidents. It is from the information provided in these notifications that the ATSB makes a decision on whether or not to investigate. While further information is sought in some cases to assist in making those decisions, resource constraints dictate that a significant amount of professional judgement needs to be exercised.

There are times when more detailed information about the circumstances of the occurrence would have allowed the ATSB to make a more informed decision both about whether to investigate at all and, if so, what necessary resources were required (investigation level). In addition, further publicly available information on accidents and serious incidents would increase safety awareness in the industry and enable improved research activities and analysis of safety trends, leading to more targeted safety education.

To enable this, the Chief Commissioner has established a small team to manage and process these factual investigations, the Level 5 Investigation Team. The primary objective of the team is to undertake limited-scope fact-gathering investigations, which result in a short summary report. The summary report is a compilation of the information the ATSB has gathered, sourced from individuals or organisations involved in the occurrences, on the circumstances surrounding the occurrence and what safety action may have been taken or identified as a result of the occurrence.

The summary reports detailed herein were compiled from information provided to the ATSB by individuals or organisations involved in an accident or serious incident between the period 1 December 2009 and 30 March 2010.

On the early evening of 31 January 2001 at Melbourne International Airport, Boeing 777-300 A6-EMM aborted its take-off run at low speed as a result of a failure within the left (No.1) engine. Although the failure was associated with a large compressor surge within the engine, no subsequent fire developed and the aircraft was able to safely return to the terminal building on its remaining serviceable engine.

Failure of the RB211 Trent 892 engine as fitted to the aircraft was a result of the release of a single blade from the low-pressure compressor (fan) rotor disk. The blade release caused extensive damage to the remainder of the fan and the intake shroud, however the event was fully contained. The only escape of debris from the engine was small, low energy fragments, causing minor damage to the fuselage and the opposite engine.

Field and laboratory examination of the released blade found that progressive fatigue cracking had resulted in the loss of two major sections from the blade dovetail root. The remaining material was subsequently unable to carry the centrifugal loads associated with the accelerating engine and failed in ductile shear, allowing the release of the blade from the rotor slot. No defects or other anomalous material or manufacturing features were found to have contributed to the crack development.

The blades installed within the Trent 892-17 engine were an approved variant of the original design, incorporating an undercut radius between the dovetail faces and the blade body. The modification was developed in order to avoid 'edge of bedding' stresses that had been implicated in blade cracking on development engines. Cracking of the released blade had initiated within this undercut radius on both sides of the shear key slot; locations that had been identified by finite element techniques as areas of high localised stress. Extensive galling of the seating surfaces was also found on all blades, indicating the long-term inadequacy of the dry film lubricant applied to the blade dovetail faces. The galling and micro-welding damage can readily interfere with the distribution of loads across the seating surfaces, leading to elevated stresses within the blade root.

Blade failure was thus attributed to an interaction of the following -

• Design - provided for areas of localised high tensile stresses arising from operating loads.
• Operating Stresses - act on the blade to produce cracking in areas highlighted by the design. In the absence of defects predisposing the blade to failure, the development of cracking implies elevated operating stress levels.
• Blade - Disk Connection Problems - galling of the dovetail surfaces indicates the potential for uneven load distribution through the connection, leading to increased stresses within the blade root and thus a greater disposition to fatigue cracking.

Although several studies have reported the common threats and errors identified in line operations safety audits (LOSAs) of high-capacity regular public transport (RPT) operations (Klinect, Wilhelm & Helmreich, 1999; Veilette, 2005; Thomas, 2004), there is little information on the types of threats and errors faced by pilots in other parts of the aviation industry.

This report catalogues the most common threats to operations, and errors made by pilots, in aerial work and low-capacity air transport operations, as perceived by flight instructors, check-and-training pilots, chief pilots and line pilots. The aim of this report is to provide a snapshot of these perceived threats and errors, along with ratings of safety deficiencies, and to offer some suggestions in how to deal with threats and errors.

This publication represents the last in a series of annual reviews, dating back to 1999-2000.

Over the last ten years, the Bureau has built a reputation as a world class investigative organisation. This has been chronicled through the ten annual reviews which the ATSB has released.

From 1 July 2009, the ATSB has taken on new annual reporting responsibilities which will result in the publication of a very different document. This change is entirely appropriate given the ATSB's status as a newly established statutory agency. However, consistent with our new mandate, I know the Commission will be looking for additional vehicles, similar to the Annual Review, to share the insights our investigations have uncovered and to promote transport safety.

As the ATSB's first Chief Commissioner, I am proud to lead the fine organisation I have inherited from Kym Bills. The successes achieved over the last ten years provide us with a solid foundation on which to achieve the expectations of government. I thank Kym for his dedication, hard work and for his outstanding legacy.

Martin Dolan
Chief Commissioner

This report tables rail safety occurrence data by state and territory between 1 January 2001 and 30 June 2009. Data is adjusted biannually to reflect new information that comes to light during the reporting period. There is a lag period of approximately 3 to 4 months between the end of the 6-monthly reporting period and publication of this data. The data is presented as counts, and normalised using kilometres travelled and number of track kilometres. Data presented in this report conforms to ON-S1: Occurrence Notification Standard 1 (2004) and OC-G1: Occurrence Classification Guideline 1 (2008). This report excludes tram and light rail or monorail operations.

This report provides Australian aviation accident and incident, collectively termed occurrence, data for the period 1 January 1999 to 31 March 2009. This data was provided to the Australian Transport Safety Bureau by 'responsible persons' as defined in the Transport Safety Investigation Regulations 2003, Part 2.5. The data excludes non-VH registered operations in the sport aviation category (except for Tables 1 and 2 which shows all occurrences), and is current as at 31 March 2009.

The data will be adjusted quarterly to reflect new information received during the reporting period.

In late 1992, the Bureau of Air Safety Investigation (BASI) noted a large increase in violations of controlled airspace (VCAs). Whereas in most of 1991, there had been around 25 such incidents per month, in December 1991 there were 42 of these incidents and throughout 1992 BASI received an increasing number of VCA notifications. The increase in VCAs was of particular concern as it may have reflected difficulties with the implementation of the Airspace Management and Air Traffic Services (AMATS) changes to Australian airspace. A VCA is a serious incident because of the risk of a collision between the intruder and an aircraft under air traffic control (ATC).

In 1992 a study (RP/92/10) was performed to examine VCA occurrences. The report found that VCAs had increased sharply following the introduction of the AMATS system in late 1991.

The aim of this report is to provide updated information on the VCA situation. As an update on the 1992 VCA report, the most recent six-month period, January to June 1994, will be examined.