The ATSB Annual Review 2003 documents ATSB's achievements and safety activities from 1 July 2002 to 30 June 2003 and outlines its business planning for 2003-2004

Executive Director's message

During 2002-03, the ATSB assisted the Minister for Transport and Regional Services with new legislation to enable the Bureau to investigate rail accidents on the increasingly important interstate system. The Transport Safety Investigation Act 2003 (TSI Act) also updates and harmonises the Bureau's aviation and marine investigative powers. The Transport Safety Investigation Regulations 2003 were also finalised this year following industry consultation and commenced together with the TSI Act on 1 July 2003.

In 2002-03 the ATSB further developed its website www.atsb.gov.au which contains the new legislation and all ATSB reports, recommendations, and key safety information and receives more than five million hits' each year.

In August 2002, the Bureau received national tertiary accreditation for five years for its internal competency-based Diploma in Transport Safety Investigation. The Diploma will validate that ATSB investigators have reached a minimum competency standard linked to investigator work level standards.

The ATSB has worked closely with state and territory transport agencies and other major stakeholders, through the National Road Safety Strategy Panel, and coordinated the development of a National Road Safety Action Plan for 2003 and 2004. The Action Plan was endorsed by Australian Transport Council (ATC) Ministers in November 2002 and covers priority areas including more effective speed management, expansion of road-based treatments, enhanced drink-driving deterrence, and measures to reduce fatigue-related harm. The Action Plan seeks to accelerate progress towards reducing the national road fatality rate by 40 per cent by 2010.

Senator Ron Boswell in his role as Parliamentary Secretary, released a number of well-received ATSB research and statistical reports and a number of other road safety publications throughout the year. A special analysis of fatal crashes over the Christmas/New Year holiday period was undertaken at the request of the Minister. The ATSB also worked closely with the National Road Transport Commission to develop a heavy vehicle safety strategy which was approved by ATC Ministers in May 2003.

The ATSB continued to participate in rail safety investigations at the invitation of state governments. Since 1999, the Bureau has undertaken or taken part in 14 investigations. Most have been in Victoria, but others have involved WA, NSW, Queensland and SA. Investigations have brought about important safety changes including to operational practices, infrastructure and regulation. The ATSB highlighted the potential inadequacies with deadman's handle' braking devices in the event of driver incapacitation in its Footscray and Epping reports.

In 2002-03, the 13 marine reports released included the October 2002 report of a ballast tank explosion on the Hong Kong registered Nego Kim with eight fatalities. Its recommendations led to both operator safety action and broader recommendations for improved safety procedures for future painting and similar work in enclosed spaces.

The ATSB released 78 final air safety investigation reports during 2002-03. A major report on maintenance problems with the Ansett Boeing 767 fleet has been especially well received in Australia and internationally and has been nominated for an international air safety award. The Bureau was pleased that in many cases safety action was undertaken obviating a need for a recommendation. Most recommendations made also led to positive safety action.

At the invitation of the East Timor Government the ATSB is leading an investigation into the fatal crash of an Ilyushin IL-76TD aircraft near Baucau, East Timor in a joint investigation with the Australian Defence Force and in cooperation with Russian investigators.

The findings on 12 September 2002 of a WA Coronial inquest into a charter accident involving Beech King Air VH-SKC included some criticisms of the ATSB. While the Bureau accepted that in hindsight there were areas it could improve upon in future investigations if additional resources were applied, other criticisms were not accepted, including criticism of the basis for independent ATSB no blame investigations under Annex 13 to the Chicago Convention.

A Coronial inquest into the accident involving Whyalla Airlines Piper Chieftain VH-MZK commenced hearings on 22 July 2002, and the SA State Coroner delivered his findings on 24 July 2003. The process also involved civil damages litigation in the US and required substantial Bureau resources to be diverted from other safety priorities. The ATSB formally reopened its VH-MZK investigation after the US engine manufacturer issued a service bulletin in September 2002 which included MKZ's left crankshaft. The ATSB will deliver a supplementary investigation report later in 2003.

During the year the Bureau continued to liaise with and seek to improve cooperation and mutual understanding with coroners around Australia, and this remains a priority for 2003-04 based on the ATSB's new legislative framework. The ATSB is reliant on coroners to assist with forensic and pathology testing.

I am again grateful to the Deputy Prime Minister and Minister for Transport and Regional Services, the Hon. John Anderson, to our Parliamentary Secretary, Senator the Hon. Ron Boswell, and to the Department Secretary Mr Ken Matthews, for their support throughout the year. I also acknowledge the bipartisan support the ATSB has received for its safety work and in the course of the passage of the TSI Act.

Kym Bills

The adequacy of MBZ procedures to ensure the safety of Instrument Flight Rules (IFR), Regular Public Transport (RPT) and charter aircraft has been questioned several times since their inception in 1991. The former Bureau of Air Safety Investigation (BASI) recommended in 1993 that, to enhance safety within MBZs (then called MTAFs), areas such as pilot education and training, along with stricter surveillance and enforcement of procedural compliance, be reviewed. BASI further recommended in 1997 that options for pilots to confirm the correct operation of communication equipment be examined. The current study reviews the available data for airspace-related occurrences in MBZs since 1994. Given the limited detail available for the majority of occurrences, caution must be used when interpreting the results of the analysis.

Light utility helicopters made up half the fleet of registered helicopters in Australia yet were involved in 72 per cent of helicopter accidents between January 1985 and December 2003. This report compared the relative safety of four light utility helicopter models. These are the: Robinson R22, 47G (made variously by Bell Helicopter Company, Agusta SPA Costruzioni or Kawasaki Heavy Industries), 269 (made by Hughes Helicopters or Schweizer Aircraft Corporation) and Hiller UH-12E. These helicopters are primarily single engine, reciprocating engine aircraft and the demand for them in Australia is high. The number of light utility helicopters on the civil register grew by 36 per cent between 1990 and 2002. The aim of this report was to determine if any particular light utility helicopter model has a higher risk profile than similar aircraft. For each of the light utility helicopter models the report compared accident trends (fatal and non-fatal), accident rates per registered aircraft, fatal accident rates per hours flown and accident rates per hours flown.

The purpose of this publication is to examine trends in the numbers of transport accident deaths in Australia in the 1980s and 1990s in the light of the most recent comparable data from most other countries that are members of the Organisation for Economic Cooperation and Development (OECD). Overall, the data indicate that in the period from 1980 to 1999 Australia's transport safety improvement compared favourably with that of other OECD countries and performance reached OECD median levels in the 1990s.

Data for this publication have been obtained from the World Health Organisations Mortality Database but responsibility for the analyses presented here rests solely with the ATSB.

The OECD was formed in 1961 to promote economic cooperation and development among its members. Current member states are Australia, Austria, Belgium, Canada, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Japan, South Korea, Luxembourg, Mexico, Netherlands, New Zealand, Norway, Poland, Portugal, Slovakia, Spain, Sweden, Switzerland, Turkey, the UK and the USA.

The purpose of this publication is to provide an overview of level crossing accident fatalities in Australia.

When fishing in waters off the Australian coast, fishermen will encounter large trading ships. Unfortunately, sometimes ships and fishing vessels collide. The ATSB has investigated 21 of these collisions since 1990. In two collisions investigated, the skippers of the fishing vessels were trapped in their wheelhouses and drowned when the vessels sank. The investigations have revealed that in almost all the collisions, there were similar factors present which contributed to the accident and precautions had not been taken that may have saved a life or at least aided the search for survivors.

October Audit Report of the Australian Transport Safety Bureau (ATSB) of Australia (Field work conducted in Canberra, 31 May to 4 June 2004).

Executive Summary

The ICAO audit team commended the positive and professional approach of the ATSB in proactively seeking the audit. The team was highly satisfied with the legislative and organizational framework established by Australia and the ATSB enabling the conduct of aircraft accident and incident investigations. Nevertheless, the audit focussed on all areas related to accident and incident investigation and found possible areas of improvement.

The Transport Safety Investigation Act 2003 (TSI Act) is the legislative framework for transport safety investigations in aviation, marine and the interstate rail system. The TSI Regulations 2003, giving effect to the TSI Act, came into force at the same time as the TSI Act on 1 July 2003. Together, the TSI Act and the TSI Regulations comply with Annex 13 requirements and have the necessary provisions to enable the ATSB to effectively conduct or participate in aircraft accident and incident investigations. The ATSB has notified its differences to ICAO in respect of Annex 13. While section 17 of the TSI Act automatically endorses any amendments to ICAO SARPs and gives them the force of Australian law, the ATSB has not yet formalized its process for reviewing the SARPs and identifying its differences.

The ATSB has its headquarters in Canberra and two regional offices (in Brisbane and Perth). The ATSB is adequately organized and supported by appropriate technical and non-technical staff. However, the ATSB has not established a process for determining staff requirements needed to adequately complete all tasks in its area of responsibility. When establishing its Business Plan, the ATSB took into consideration the Departments Portfolio Budget Statements; however, the ATSB developed the performance indicators of its business plan based on the budget allotted to it. As a result, the number of smaller investigations and the scope of more complex investigations change depending on the availability of financial resources. Ideally, the number of accidents, serious incidents and associated safety issues should be used as a basis for the determination of the budget. Finally, the ATSB has not put in place a system for the control and integration of the regional offices into the functionality and organizational structure of the Canberra office. The ASTB has signed several Memorandums of Understanding (MOUs) with other organizations and authorities but some important MOUs have yet to be finalized.

The ATSB is commended for having developed a very comprehensive training policy and programme, which includes a diploma course entitled Transport Safety Investigation (TSI) Diploma Course. The ATSB training policy requires all personnel who joined the ATSB after 1 January 2000 to complete the TSI Diploma Course. Investigators who have taken or are currently taking this course maintain structured training files in accordance to the training programme followed. However, not all investigators have undergone the TSI Diploma Course. As a result, some investigators are not part of the formal diploma programme and do not maintain a documented record of all the types of training and briefings that they have been provided with.

The ATSB provides its staff with all the necessary facilities and equipment. However, the review of some of the equipment to be used by investigators revealed shortcomings in serviceability and record keeping. The ATSB has developed a new Safety Investigation Policy and Procedures Manual but has not yet formally approved it. The procedures established by the ATSB for the notification, investigation and reporting of aircraft accidents and incidents, found in several manuals, are comprehensive and in conformity with Annex 13 requirements. The ATSB focuses primarily on fare-paying passengers and on fatal accidents (unless they involve sport aviation), therefore some accidents that are considered to have little potential benefit for the prevention of re-occurrences may not be investigated in detail. In such cases, the ATSB does not necessarily attend the scene, conduct an in-depth investigation or produce an extensive report. Autopsy reports are obtained by the ATSB but are not always complete. By Australian legislation, medical examination and toxicological testing of surviving flight crew and aviation personnel cannot be performed after an accident.

Safety recommendations are issued by the ATSB in conformity with Annex 13 requirements. ADREP Preliminary Reports and Data Reports sent by the ATSB to ICAO were incomplete, partly due to the differences in the taxonomy format. Since the ATSB is in the process of acquiring a new accident and incident data reporting system, it is recommended that the new database system be ADREP-ECCAIRS compatible in order to facilitate reporting and international exchange of data. Between 1988 and February 2004, the ATSB managed a voluntary incident reporting system named Confidential Aviation Incident Reporting (CAIR). A new voluntary non-punitive incident reporting scheme, entitled Aviation Self-Reporting Scheme (ASRS), replaced the CAIR on 21 February 2004 but has not yet been broadened to receive CAIR reports, pending further legislative measures. In addition to accident and incident investigation, the ATSB undertakes safety data analysis and research. All the ATSB reports, safety recommendations and key safety information are available on the ATSB website.

Updated January 2008

Time and again, fatigue has been a major factor in marine incidents and the collision described below is a perfect example of the effects of fatigue. It is a matter of sheer luck that more fishermen have not been killed as a result of fatigue-related accidents.

Executive summary

Australian aviation is, by world standards, extremely safe. Fatal accidents in regular public transport (RPT) operations are low and, since the late 1960s, have been confined to low capacity operations. Australia has not had a high capacity RPT fatal accident since 1968 and has not had a RPT jet fatal accident. 

The vast majority of Australian civil fatal aircraft accidents occur in general aviation (GA) operations. This study examined Australian ‘VH-registered’ civil aircraft involved in GA fatal accidents for the period 1991 to 2000, and covers fatal accident numbers and rates by aircraft type and operational grouping, timing of accidents, injury levels, pilot demographics and fatal accident types. 

Between 1991 and 2000 inclusive, there were 215 fatal accidents and 413 associated fatalities. Over the ten-year period there were 1.2 GA fatal accidents per 100,000 hours flown. The annual fatal accident rate decreased from 1.6 fatal accidents per 100,000 hours flown in 1991 to 0.9 in 2000. While this decrease was not statistically significant, subsequent data to the end of 2002 do indicate a statistically significant decrease. Statistically significant variations were identified at certain times of the day and week, indicating that occurrences were more likely to be fatal accidents at certain times. The rate of general aviation fatal accidents was found to be significantly higher during the evening between 1700 and 2059 than the rest of the day and the private/business fatal accident rate was found to be significantly higher over the weekend than during the week. Reasons for these findings could not be clearly identified. 

The population of pilots involved in fatal accidents was compared with the present population of active general aviation pilots against certain demographic criteria. 

The risk of a fatal accident per hour flown was greater for pilots who had between 50 and 1,000 hours aeronautical experience than pilots who had more than 1,000 hours experience. However, with the low number of pilots involved in fatal accidents, small changes in the demographics of pilots involved in fatal accidents can lead to large changes in the risk associated with different age and experience groupings. 

The fatal accidents were grouped using a classification scheme developed within the ATSB so that a consistent and useful description of the accident types could be achieved. The re-classification and re-coding of the accidents enabled a more accurate description of the larger groupings of fatal accidents, which could provide a greater opportunity to accurately target specific risk areas in general aviation operations. 

The majority of fatal accidents (82 per cent) fell into three main groups: 

• controlled flight into terrain
• managed flight into terrain
• uncontrolled flight into terrain. 

For the purpose of this report these accident types were defined as: 

• Controlled flight into terrain (CFIT) - an event where an aircraft collided with obstacles, objects or terrain during powered, controlled flight with little or no awareness on the part of the pilot of the impending impact. 
• Managed flight into terrain (MFIT) – an event where an aircraft collided with obstacles, objects or terrain while being flown under limited control or reduced performance, with insufficient height/performance to reach a designated landing area. 
• Uncontrolled flight into terrain (UFIT) - an event where an aircraft collided with obstacles, objects or terrain after control of the aircraft was lost in-flight (includes cases where the pilot became incapacitated) but the aircraft structure did not change prior to impact. 

UFIT fatal accidents were the most prevalent of the fatal accident types (46 per cent), followed by CFITs (30 per cent) and MFITs (6 per cent). Accidents that did not fall into one of these three main groupings were categorised separately, but were not sub-categorised to the same extent. 

The vast majority of low-level UFIT fatal accidents (approximately 90 per cent) could be described as accidents where the pilot’s control inputs (or lack of inputs) initiated a loss of control. In almost a quarter of these cases, turbulence or windshear may have also contributed to the loss of control. In contrast, UFIT fatal accidents during ‘normal’ operations were more likely to have had an initiating factor such as a loss of engine power, loss of reference to the external environment, aircraft system or airframe problem, pilot incapacitation etc., with around 20 per cent being primarily the result of pilot action or inaction. This disparity suggests that many of the loss of control events during low-level operations could have been recovered had the aircraft been at a greater height. For fixed wing operations, a higher proportion of UFIT accidents were private/business operations (2/3), compared with MFIT or CFIT accidents (1/2). 

The next largest fatal accident grouping was controlled flight into terrain accidents (CFITs). The majority of CFIT fatal accidents occurred during low-level operations, when the pilot could see the environment. Most of these accidents were wirestrikes. Pilots involved in CFIT fatal accidents who were flying aircraft unnecessarily low, accounted for a quarter of all the fatal CFITs and 42 per cent of fatal CFITs during low-level flying. The large majority of CFIT fatal accidents from ‘normal’ operations occurred when the pilot was not able to see the outside environment, whether operating under VFR or IFR. 

The accident classifications used in this report promote greater understanding of the types of fatal accidents that have occurred by focusing on the state of the aircraft at the time it sustained damage or a person was fatally injured. The events or circumstances that precipitated the accident types highlight areas where it is possible to intervene in the sequence of events to avoid a fatal accident or reduce the severity of an accident. 

The characteristics of each accident group were markedly different, and the sub-categorisation of accidents within each group was therefore also different. The majority of CFIT fatal accidents were initiated by an impact with an obstacle or terrain. In UFIT accidents the event that led to the situation becoming a fatal accident generally happened while the aircraft was still flying. MFIT accidents were generally fatal because of the nature of terrain encountered at the time of impact, rather than because of the nature of the event that precipitated the accident.

Cannabis is a commonly used recreational drug, which has widespread effects within the body. Smoking is the most common form of administration. The adverse effects of cannabis on behaviour, cognitive function and psychomotor performance are dose-dependent and related to task difficulty. Complex tasks such as driving or flying are particularly sensitive to the performance impairing effects of cannabis. Chronic cannabis use is associated with a number of adverse health effects, and there is evidence suggesting the development of tolerance to chronic use as well as a well-defined withdrawal syndrome. There is also evidence that the residual effects of cannabis can last up to 24 hours. Significantly, the modern dose of cannabis is much more potent than in the past, when the majority of the research was conducted. As such, the reported adverse health effects may well be conservative. Although only a limited number of studies have examined the effects of cannabis on pilot performance, the results overall have been consistent.