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 Short 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. In addition, the ATSB may include a Safety Message that is directed to the broader aviation community.

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 January 2011 and 31 March 2011.

In the 2009-2010 financial year, the Australian Transport Safety Bureau (ATSB) completed 37 aviation, 10 marine, and 11 rail investigations where safety factors were identified using the ATSB analysis framework. From these investigations, 124 safety issues (factors that have a potential to adversely affect the safety of future operations) were identified and 141 safety actions were undertaken to address these safety issues. This report documents and analyses these safety issues and safety actions and explores the risk levels assigned to provide an understanding of where the greatest risks to each transport mode appear to lie. 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.

Inadequate procedures or the lack of procedures were a common safety issue found by ATSB investigations for all transport modes. In rail investigations, problems with safety management process practices were slightly more common than problems with procedures. When safety issues are assessed by the level of risk posed to transport safety, the lack of procedures or inadequate procedures were found to carry the most significant safety risk for all three modes.

Deck and flight operations were the functional areas that were associated with the most safety issues in marine and aviation investigations respectively. These were also the functional areas (along with navigation - pilotage for marine) that were linked to the majority of the safety issues carrying significant risk. For rail, vehicle maintenance and network operations were associated with the most safety issues of significant risk.

Proactive industry safety action was the most common way safety issues identified in investigations were addressed across the aviation and marine modes, while proactive industry safety actions made up only half of the safety actions taken by the rail mode.

Amending or adding procedures was a common proactive industry safety action for all modes. This was particularly the case for safety issues that carried significant safety risk. For marine, the proactive industry safety actions taken spread across various categories such as procedures, organisational supervision, documentation, education, and training. In addition, proactive changes or additions to documentation were the second most common proactive industry safety action for the aviation industry.

Everyday errors such as incorrectly transcribing or inadvertently dialling a wrong telephone number normally have minimal consequences. For high-capacity aircraft operation, the consequence of such errors can be significant. There have been numerous take-off accidents worldwide that were the result of a simple data calculation or entry error by the flight crew. This report documents 20 international and 11 Australian accidents and incidents (occurrences) identified between 1 January 1989 and 30 June 2009 where the calculation and entry of erroneous take-off performance parameters, such as aircraft weights and 'V speeds' were involved. Importantly, it provides an analysis of the safety factors that contributed to the international occurrences and suggests ways to prevent and detect such errors.

A review of the international and Australian occurrences showed that these types of errors have many different origins; with crew actions involving the wrong figure being used, data entered incorrectly, data not being updated, and data being excluded. Furthermore, a range of systems and devices have been involved in these errors, including performance documentation, laptop computers, the flight management computer, and the aircraft communications addressing and reporting systems. The consequences of these errors also ranged from a noticeable reduction in the aircraft's performance during the take-off, to the aircraft being destroyed and loss of life.

The most common contributing safety factor identified related to crew actions (39 per cent), including monitoring and checking, assessing and planning, and the use of aircraft equipment. This was followed by absent or inadequate risk controls (31 per cent), mostly centred on poor procedures, non-optimally designed aircraft automation systems, inappropriately designed or unavailable reference materials, and inadequate crew management practices and training. Common local conditions (27 per cent) involved inadequate task experience or recency, time pressures, distractions and incorrect task information.

Different airlines use, and different aircraft types require, different methods for calculating and entering take-off performance parameters, which means there is no single solution to ensure that such errors are prevented or captured. This report also discusses several error capture systems that airlines and aircraft manufacturers can explore in an attempt to minimise the opportunities of take-off performance parameter errors from occurring or maximise the chance that any errors that do occur are detected and/or do not lead to negative consequences.

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. In addition, the ATSB may include an ATSB Comment that is a safety message directed to the broader aviation community.

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 October 2010 and 31 December 2010.

This report tables rail safety occurrence data by state and territory between 1 January 2001 and 31 December 2010. 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, light rail and monorail operations.

This report documents the number and types of safety occurrences involving loading of high-capacity aircraft across a 7-year period to raise awareness within the aviation industry of the associated issues. Incorrect loading of containers, pallets or bags into aircraft can result in them being outside of weight or centre of gravity operating limits, and this may influence aircraft controllability. Most high-capacity aircraft loading occurrences are relatively minor, with cargo locks not being raised being the most common. More serious occurrences have involved shifting cargo and unlisted cargo being loaded onto aircraft. Aircraft performance has been affected in a small number of cases, and the result has been rejected take-off, extra stabiliser trim, or aircraft control difficulties.

The Human Factors Analysis and Classification System (HFACS) is a hierarchical taxonomy that describes the human factors that contribute to an aviation accident or incident that is based on a chain of- events theory of accident causation and was derived from Reason's (1990) accident model.

The objectives of this exploratory study were to identify relationships between the factors of the HFACS taxonomy and to assess the usefulness of HFACS as a predictive tool. The associations found in this study may assist investigators in looking for associated factors when contributing factors are found. Also, when using the HFACS taxonomy to identify areas for intervention, the relationships found may also guide intervention in associated areas for a holistic, systems approach to improvement.

This exploratory study found a number of strong positive relationships between factors at different levels of the model. However, based on the amount of variation explained by the logistical regression statistical models, it appears that HFACS is a more effective predictive framework when used to predict unsafe acts than when used to predict higher levels within the taxonomy.

The Australian Transport Safety Bureau (ATSB) formalised the concept of outside influences and added five factors within this grouping to the HFACS model in this study. The outside influences factors proved to be important additions to the HFACS model as they were associated with factors at all levels of the HFACS taxonomy.

The results have also shown that it is not always the case that higher-level factors predict only the lower-level factors directly below them. For example, inadequate supervision predicted precondition for unsafe acts, such as adverse mental states and crew resource management issues, as well as skill-based errors (two levels down).

With the intensity of agricultural related aviation activity increasing at this time of the year with activities such as locust spotting and spraying, it is important that all aerial work pilots maintain an awareness of the fatal consequences of fatigue while carrying out these activities.

The ATSB was recently notified of an incident where a pilot undertaking locust spotting activities needed to be woken by an observer on the aircraft. The pilot reportedly flew part-time, and his fatigue may have been related to his other activities as a farmer.

Not only is fatigue brought on by the amount of flying time and the type of flying you are doing, it is also attributable to what you are doing when not flying. If you have another job, especially one that requires long hours and involves strenuous activity or long periods of concentration, you're more prone to fatigue while flying.

What are the effects of fatigue?

Fatigue reduces your ability to conduct flying tasks. Specifically, the effects include:

• slowed reaction times
• reduced vigilance
• slower mental abilities
• memory problems
• poor communication
• reduced alertness
• poor decision-making
• fixation on a single task
• actually falling asleep while flying.

How do I know if I'm fatigued?

Research shows that people often find it difficult to recognise they are fatigued. Fatigue can be short-term (acute) or long-term (chronic). Acute fatigue can occur in a matter of hours as a result of excessive and sustained mental or physical activity. Chronic fatigue is experienced when the normal period of rest or sleep over consecutive days is insufficient.

Try this checklist

You can use the following self-assessment checklist to give yourself an objective assessment of your fatigue risk before you fly:

• did you have less than eight hours sleep last night
• have you missed out on adequate sleep over the previous nights
• has your sleep been disrupted
• have you been awake and/or at work for an extended period
• have you had less than six hours sleep in the last 24 hours (or 14 hours sleep in the last two days)
• have you had a recent illness or injury
• are you affected by medication, other drugs or alcohol.

If your answer to one or more of these questions is yes or even maybe, you're at a higher risk of fatigue.

Tips for countering fatigue

Arrange work and personal activities to ensure you get adequate sleep each night (eight hours).

Look out for cumulative sleep loss - missing a couple of hours of sleep each night adds up to sleep debt.

Be conscious of the quality of your sleep - if your sleep quality has been poor, it may not be safe to fly:

• interruption to sleep can be from stress, babies crying, sleeping disorders, shift work, jet lag or any number of factors.
• degraded sleep quality significantly lessens the restorative effect of sleep.

Avoid flying towards the end of a day; especially if you woke early or if you've been active throughout the day.

Take extra precautions if you haven't had a day of in a while or having been working long hours.

Plan your activities for a maximum of two-hours flying, with a rest in between each flight, and a maximum of eight hours flying in a day.

When assessing your potential fatigue levels, take into account all activities you do throughout your day - not just flying.

Napping during the day may help recharge the batteries:

• limit your nap to between 20 and 40 minutes
• wait 30 minutes after a nap to ensure you are fully awake before you fly.

Proper nutrition and plenty of water helps keep you alert:

• minimise fatty and high-sugar foods
• don't rely on caffeine (coffee, energy drinks) as they only provide short-term relief from the effects of fatigue.

Share this information with your co-workers and family. Ask them to keep an eye on your performance. Do the same for others you fly with.

Remember, getting enough quality sleep is essential to avoiding fatigue.

Summary

Most aerodromes in Australia are located in uncontrolled airspace and consequently do not have an air traffic control presence. At and around non-controlled aerodromes, pilots are responsible for making themselves aware of nearby aircraft and maintaining separation. This report aims to provide pilots with an appreciation of the types of safety events that are associated with operations at non-controlled aerodromes and provide education on expected behaviours to assist pilots in being prepared for the risks.

Generally, operations at non-towered aerodromes can be considered to be safe, but this relies on all pilots maintaining awareness of their surroundings and of other aircraft, and on flying in compliance with procedures, while being observant, courteous and cooperative. Most of the 709 airspace-related safety occurrences reported to the ATSB between 2003 and 2008 at, or in the vicinity of non-towered aerodromes, were incidents, but they also included 60 serious incidents and six accidents (mid-air and ground collisions). 

Most of the occurrences involved conflicts between aircraft, or between aircraft and ground vehicles. A large number of these involved separation issues, ineffective communication between pilots operating in close proximity, the incorrect assessment of other aircraft’s positions and intentions, relying on the radio as a substitute for an effective visual lookout, or a failure to follow published procedures. 

This report looked only at incidents and accidents prior to the introduction of changes by the Civil Aviation Safety Authority (CASA) to Civil Aviation Regulation (CAR) 166 on 3 June 2010, which affected procedures at all non-towered (non-controlled) aerodromes. Although the CAR 166 changes may in time be shown to reduce incidents and accidents, a number of issues highlighted by the occurrences documented in this report persist at non-towered aerodromes which pilots can easily address. 

This guide has been released in association with a more detailed and larger report (

What you need to do

Non-towered aerodromes have been, and will continue to be, a central component of the Australian airspace system. A number of issues related to communications, situational awareness, and following circuit procedures persist in occurrences at non-towered aerodromes that pilots can easily address to make sure that safe operations are always maintained.

The aim at all times is to achieve radio-alerted see-and-avoid, to be aware of other traffic, and position your aircraft appropriately to prevent conflicts with that traffic. Observing these simple points will help to you to do this4.

• Maintain a lookout for other aircraft at all times.
• Get a radio, and always make the standard broadcasts — even when you think there is no nearby traffic.
• Achieve radio alerted see-and-avoid by making all of the standard broadcasts within 10 NM of a non-towered aerodrome.
• Use the same procedures at all non-towered aerodromes, unless otherwise stated in the En Route Supplement Australia (ERSA).
• Be aware that any radio-equipped aircraft could be conducting straight-in approaches at non-towered aerodromes
• Avoid overflying aerodromes where possible and take note of IFR inbound and outbound routes.

Read the research report

Most aerodromes in Australia are located in uncontrolled airspace and do not have an air traffic control presence. At these non-towered aerodromes, and in the vicinity of them, pilots are responsible for making themselves aware of nearby aircraft and maintaining separation. This report aims to give pilots an appreciation of the types of safety events that have been associated with operations at non-towered aerodromes and provide education on expected behaviours to assist pilots in being prepared for the risks.

Generally, operations at non-towered aerodromes can be considered to be safe, but this relies on all pilots maintaining awareness of their surroundings and of other aircraft, and on flying in compliance with procedures, while being observant, courteous and cooperative. Most of the 709 airspace-related safety occurrences reported to the ATSB between 2003 and 2008 at, or in the vicinity of non-towered aerodromes, were incidents, but they also included 60 serious incidents and six accidents (mid-air and ground collisions). Most of the occurrences involved conflicts between aircraft, or between aircraft and ground vehicles. The most common types of occurrences involved ineffective communication between pilots operating in close proximity, separation issues, incorrect assessment of other aircraft's positions and intentions, relying on the radio as a substitute for an effective visual lookout, or a failure to follow published procedures.

This report also documents changes in the number of aircraft movements and changes in the traffic mix into 20 non-towered aerodromes since 2003. Aerodromes experiencing significant growth could potentially be exposed to higher risk. Port Macquarie, Kununurra, Ballina, and Mt. Gambier all have experienced a recent increase in large passenger transport aircraft movements.

This report looked only at incidents and accidents prior to the introduction of changes by the Civil Aviation Safety Authority (CASA) to Civil Aviation Regulation (CAR) 166 on 3 June 2010, which affected procedures at all non-towered (non-controlled) aerodromes. Although the CAR 166 changes may in time be shown to reduce incidents and accidents, a number of issues highlighted by the occurrences documented in this report are likely to persist at non-towered aerodromes, but associated risks can be minimised through greater awareness of the importance of clear and concise communications, effective visual lookout and adherence to published procedures.