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.

The status of commercial passenger operations in turbine powered single engine aeroplanes is presently under review by the civil aviation regulatory authorities of several nations. In this information paper BASI offers no argument for or against the introduction of such operations.

Present regulations on commercial passenger carriage were developed prior to the availability of the turboprop engines which are now in operation.

The Bureau of Air Safety Investigation recently conducted research into the rates of G onset and G levels experienced by a light aircraft pilot during normal aerobatics. The objective was to relate data obtained from the research to other data available from military authorities, in order to evaluate the possibility or otherwise of a light aircraft pilot sustaining G-induced loss of consciousness (G-LOC) during aerobatics.

MTAF procedures were introduced in Australia with the AMATS changes of 12 December 1991. The MTAF procedure applies at specified aerodromes. It depends on pilots making mandatory radio calls, hearing calls from other aircraft, assessing this traffic information for potential conflict, and responding appropriately with radio communication and avoiding action if necessary.

The MTAF procedure is designed to alert aircraft to all other air traffic in a designated area surrounding a particular aerodrome. The procedure mandates certain radio broadcasts and responses in these areas, and the pilots are then responsible for arranging their own separation.

In March 1993 BASI was informed that airline pilots had considerable concerns over the safety of RPT operations in MTAF areas. Reports stated that "Since the inception of MTAFs, [pilots] are experiencing conflict situations with unannounced, unalerted traffic, on a daily basis. This is resulting in numerous instances of immediate evasive action having to be initiated by aircraft operated within MTAFs".

This report was commissioned by the Bureau of Air Safety Investigation (BASI) to investigate the system of Notices to Airmen (NOTAM) following statements from some airline flight crews that current NOTAM presentation is not optimised to meet their needs. Pilots had stated that:

• Some NOTAM are not clearly written,
• The NOTAM format can be difficult to decipher,
• There is too much irrelevant information provided.

This information paper reviews the Bureau's policy on testing for drugs and alcohol, attempts to assess the prevalence of drugs and alcohol in aviation accidents and incidents, and discusses the adequacy of the present policy. The policies of Canada, the United Kingdom, and the United States are also outlined.