The safety of fishermen and people in small boats is a continuing concern in terms of safety at sea. In the course of your voyages, you encounter many types of fishing operations from dug out canoes, with sometimes a candle or oil lantern, to large fishing/factory ships. In and around the Australian coast fishing vessels tend to be less than 20 m in length with a crew of two or three. They often exhibit very bright working lights, though these should be shielded in order to ensure that the fishing lights required by the Colregs can be seen clearly.

This report examines what, if any, trends may be emerging as a result of the introduction of NAS stage 2b from 27 November 2003. Four indicators - airprox, breakdown of separation (BOS), resolution advisories (RA) and violation of controlled airspace (VCA) - were analysed to assess any net effects resulting from NAS 2b changes. There was no significant change in the rate of airproxes per aircraft movement in the 180-day period after NAS 2b was introduced relative to the 180-day period immediately before. There was also no significant change in airproxes involving RPT aircraft. There was a reduction in the rate of BOS incidents per aircraft movement in the post-NAS 2b period compared with the period immediately before, but this was not statistically significant. Analysis of RA incidents indicated no statistically significant change in the rate per movement reported after NAS 2b was introduced compared with the period immediately before. Overall, the report concludes that data currently available do not enable reliable conclusions to be drawn about NAS 2b safety trends.

Hughes 369HS, ZK-HCC Accident near Fox Glacier, New Zealand, 30 November 2003

FACTUAL INFORMATION

On 30 November 2003, a New Zealand registered Hughes 369HS, ZK-HCC, was operating on a standard scenic flight over the Fox Glacier, New Zealand. The intended track was over Fox Glacier, around Mount Cook and Mount Tasman, returning via the Fox Glacier to land at Fox Glacier township.

After a normal climb to 9,500 ft and commencing level forward flight, the pilot noticed the power turbine speed and main rotor speed reduce. The pilot descended to 6,500 ft where power was restored. Several minutes later a second power loss occurred. The pilot then carried out an emergency landing at the base of Fox Glacier. During the emergency landing the helicopter sustained damage to a landing gear skid and rolled onto its side. The pilot and passengers vacated the helicopter with no serious injuries.

A passenger had been photographing the scenic flight using a video camera. Sounds relating to the operation of the main rotor gearbox had been recorded on the video. The Transport Accident Investigation Commission (TAIC) of New Zealand was responsible for investigating this accident and requested assistance from the Australian Transport Safety Bureau (ATSB) to analyse the sounds recorded on the video camera. It was requested that the data be presented in tabular and graphical format. The Executive Director of the ATSB approved the request and the examination was conducted in accordance with the Australian Transport Safety Investigation Act 2003.

A copy of the video recorded during the accident flight was forwarded to the ATSB by the TAIC aviation investigator in charge. The video was received at the Bureau on 24 February 2004 and examined by an ATSB recorder specialist. The audio signals were downloaded and analysed using the Bureau's audio software and graphical and tabular presentations of the data were prepared.

Information relating to the operation of the helicopter's main rotor system was provided to the TAIC investigator in charge for consideration in preparing their report.

A copy of the TAIC investigation report (03-007) may be found at: www.taic.org.nz(Opens in a new tab/window) or by contacting the Transport Accident Investigation Commission, PO Box 10-323, Wellington, New Zealand.

(Cessna 404, VH-ANV Jandakot WA, 11 August 2003)

Introduction

At 0735 UTC on 11 August 2003, VH-ANV was cleared on a MANTL 1 departure from runway 24R at Jandakot airport. Onboard were the pilot and five passengers. The aircraft called ready and was cleared to climb to 3,000 feet. The aircraft rotated and the tower staff noticed a sound similar to an asymmetric operation. The aircraft was turned left and subsequently impacted the ground to the southeast of the tower near the NDB site. This Technical Analysis Investigation report should be read in conjunction with ATSB report BO/200303579.

(RB211-524 Turbofan Engine)

Examination brief

During the landing at Johannesburg International Airport on 15 March 2003, the flight crew of the Boeing 747-400 aircraft, registered VH-OJO, noted an "ENG 2 REVERSER" message displayed on the engine indication and condition alerting system (EICAS) after the application of reverse thrust. Airport personnel subsequently found debris on the runway and taxiway used by the aircraft.

An engineering examination of the number-2 engine nacelle by the operator's ground staff established that both panels from the integrated nozzle assembly (INA) drive fairing had been lost, as well as two thrust reverser blocker doors, with a third door substantially damaged. The core assembly of the engine (an RB211-524G/T model) was not damaged.

The operator reported the incident to the South African Civil Aviation Authority, who took the liberated debris into their possession for an engineering investigation of the failures. The components were subsequently sent to the Australian Transport Safety Bureau (ATSB) for further study and engineering analysis. The ATSB commenced a technical analysis investigation into the failure of the components on 1 July 2003. This report presents the findings of the ATSB analysis and conclusions drawn as to the mechanism of failure.

A seaman was killed and two other seamen were seriously injured when the lifeboat they were in fell 20 metres to the water after the wire falls parted. The limit switches did not operate, and the falls parted when the davits came up to their stops with the winch motor running. Another fatality was only prevented by a crewmember's safety helmet. This was one of three similar accidents where lives were put at risk.

Pratt & Whitney Canada PW118A, Engine s/n 115120

INTRODUCTION

Airnorth Regional experienced operational problems with a Pratt and Whitney Canada PW118A engine (engine s/n PC-E 115120). The problems ranged from hung starts resulting in aborted hot starts to vibration (sub-idle vibration) and noise from the high-pressure (HP) rotor. These problems occurred over a period of several days. In order to resolve the problems, the engine was removed from the aircraft to allow further investigation through disassembly.

Disassembly revealed that the bolted joint between the HP turbine disk and turbine stub shaft had failed. Of the five bolts used in the assembly, two had fractured in the threaded section. The remaining three bolts exhibited varying degrees of bending and thread damage.

After a detailed examination of the bolts by Pratt and Whitney Canada, it was concluded that the fracture of the two bolts and cracking in the remaining bolts was caused by corrosion fatigue, with sulphur being identified as the corrosive agent. It was proposed that the presence of sulphur was the result of environmental contamination.

Airnorth brought the bolt failure and subsequent analysis by the engine manufacturer to the attention of the ATSB. An independent review of the bolt failure analysis was undertaken by the ATSB.

Introduction

The problem of collisions at railway crossings is an on-going one for rail operators, track providers and regulators and road authorities in Australia. While the number of deaths and injuries is small in comparison to other road casualties and has been reduced considerably in recent years, they are the most serious safety issue faced by the rail system in Australia.

The genesis of the present project was at a special meeting of the Australian Transport Council (ATC) on 8 August 2002 that considered the outcome of recent tests of locomotive auxiliary lighting. It was agreed at that meeting that the SCOT Rail Group, in consultation with the rail industry, develop a strategic approach to managing the full range of level crossing issues. It was further agreed that Austroads and Rail Group were to review available research on train lighting and visibility and report back to ATC at its meeting on 8 November 2002 on the need for any further research. The Australian Transport Safety Bureau was required to produce this review on behalf of Austroads and Rail Group and has commissioned ARRB Transport Research Ltd to undertake the work.

The essential purpose of the present report is therefore to advise on the need for, the feasibility of, and the potential benefits of, further research into train lighting and conspicuity that will deliver significant reduction in road safety trauma.

Number of collisions and their associated costs

In the period 1996-2000, it is estimated that approximately 36 crashes per year occurred at passive crossings throughout Australia. These crashes resulted in an average of four deaths and six serious injuries per year. The average annual cost of collisions at railway level crossings was estimated to be at least $24.8 million for all crossings, including $16.3 million for active crossings and $8.3 million for passive crossings. As fatality data for NSW were not available, these estimates were based on the assumption that the distribution of injury outcomes for NSW is similar to that in other states. The estimates are regarded as minimums, since the data for South Australia, Western Australia and the Northern Territory were incomplete. They are based on personal injuries recorded in the road crash system and do not reflect the major losses to the rail system that can occur as a result of a collision with a road vehicle. Rail system loss data are not kept in a systematic manner by all rail operators. Data that were obtained indicated very high losses associated with some incidents. The fatality rate at level crossings per 100,000 population is considerably lower in Australia than in the United States and Finland.

Case for improving train conspicuity

Since there are fewer locomotives (approximately 2300) than passive crossings (approximately 6000), and since locomotive lighting treatments are likely to cost less than even the low-budget active warning systems currently being trialled, treating locomotives appears to be an attractive option. Increasing the conspicuity of locomotives would cost far less than providing active treatments at all passive crossings. However, there is presently insufficient research evidence to estimate the proportion of collisions at passive crossings that would be prevented by such treatments. While available data suggests that active warnings would reduce crashes by more than 60 per cent (Schulte 1976), it is not possible to say by how much increased conspicuity would reduce collisions.

Vehicle/train collisions

Under Australian conditions, approximately 70% of collisions occur during daylight and 30% occur at night. Daytime collisions also predominate in the US, but the difference between daytime and night-time crash occurrence is less marked than in Australia.

In Australia, approximately 65% of crashes involve trains running into road vehicles and 35% involve road vehicles running into the side of trains.

Seven contributing factors related to the driver of the road vehicle have been identified:

• Not detecting the crossing
• Stalling
• Not detecting the train
• Being distracted
• Inaccurate expectancies
• Deliberate risk taking
• Misjudging train speed.

There are very few cases of stalled vehicles on the tracks, and deliberate risk taking is not possible unless the driver has already seen the train. The important contributing factors are, on the one hand, not detecting the train, to which distraction and inaccurate expectancies regarding the presence of a train may contribute; and on the other hand, misjudging the speed of the train. It is not known to what extent each of these factors contributes to collisions at railway level crossings. It seems inherently unlikely that adding more lights to the train would result in more accurate (or at least more cautious) perceptions of train speed. This leaves cases which involve not detecting the train, distraction and expectations that a train will not be present as events where adverse outcomes could be avoided by better train conspicuity. Unfortunately, it is not possible to say what proportion of cases this involves, or by how much increased conspicuity (assuming effective increases in conspicuity were possible) is likely to reduce this.

Lighting standards

The Australian Rail Operations Unit, in consultation with the rail industry, is in the process of developing a draft Code of Practice for the Defined Interstate Rail Network to provide uniform guidance for the design and construction of rolling stock. The relevant volume of the Code includes provisions for lighting and reflectorised material on trains. The draft code has mandatory provisions for headlights and 'road visibility lights', which are similar to crossing lights. Reflectors are optional, but where provided the reflective sheeting must be to Class 1A standard and there are mandatory provisions for minimum dimension, placement and colour.

The present report discusses characteristics of different lighting systems and puts forward an outline for the development of photometric models to predict the relative visibility of different lighting treatments.

Empirical studies of the effectiveness of auxiliary lighting treatments are reviewed. There is evidence to suggest that all auxiliary lighting treatments are effective and increase detectability or improve estimations of time to arrival compared to headlights alone. A study for the US Federal Railroad Administration showed that crossing lights were the most effective treatment. Studies have also shown that strobe lights can improve detection when added to locomotives previously equipped with headlights alone. However, a recent study for Western Australian Government Railways indicated that a single strobe light did not improve detection when added to locomotives already fitted with both headlights and crossing lights.

Possible means of improving train conspicuity

It is possible that daytime crashes might be reduced by adding coloured strobe lights or by selection of colour schemes which better contrast with the background against which locomotives on particular lines are viewed.

Although reflectorised panels may be effective in improving conspicuity, they may not be effective at crossings where the road does not cross the rail track at right angles. Self-illuminated devices, similar to those currently available as road delineators (also known as cats eyes), may be a viable alternative.

Conduct of future research

If it is decided that the scale of the problem and the potential benefits warrant further research, then it is recommended that the following procedure be followed. Future research should proceed first by careful modelling of the photometric properties of proposed conspicuity enhancing treatments. Only once there is a solid case established that a treatment has a high probability of succeeding should any field work be undertaken. The photometric modelling will probably have to be supplemented by photometric measurements and some tests with subjects using real-life visibility aids on a static locomotive to provide data for the modelling process, resolve issues which cannot be resolved theoretically and confirm the predictions of the models. The cost of the photometric modelling exercise is estimated at $75,000 and the supplementary program of measurements and tests at $15,000 to $45,000. A study of the safety margins allowed by drivers when crossing in front of a train would cost approximately $105,000, including equipment and a pilot study to confirm the feasibility of the method. The total program of recommended research would cost up to $225,000.

Evaluation of the effectiveness of conspicuity treatments in terms of crash reductions will not be practical, due to the small number of crashes available for comparison, unless the proportion of crashes prevented by the treatment is exceptionally high.

The objectives of this draft report are to: Provide objective, statistical measures of the safety of Australian aviation (excluding sport and military) Provide a document that highlights broad trends and developments that have occurred in aviation safety Provide a document that offers a basis to compare aspects of Australian aviation safety against the safety of aviation in other countries Deliver the above utilising a process that is acceptable to stakeholders. Data concerning aviation activity, the aviation industry and aviation accidents were collected from four main sources. Data are presented graphically in time series figures, and some data were tested for statistical significance using simple regression.

Birdstrikes continue to be a problem for aviation worldwide, costing approximately $US3 billion annually. Increasingly, funds are being directed towards research which focuses on bird control and avoidance methods. Two such methods which are proving to be successful, are the use of handheld laser devices to scare birds from the airport environment, and the use of the US developed Avian Hazard Advisory System (AHAS), which allows aircraft to avoid high-risk birdstrike areas. This study investigated the Australian birdstrike data for the period 1991 to 2001. Although limited, the available data was able to be used to investigate birdstrike rates, species involvement and hazard potentials, as well as providing a time of day and phase of flight analysis. Additionally, the current study highlights the magnitude of some of the impact forces exerted during a birdstrike. The data suggest that there has been a significant increase in the rate of birdstrikes being recorded in Australia since 1992 (most notably between 1998 and 2001).