The aim of this study was to investigate the feasibility of forensic DNA-based techniques in identifying species involved in Australian aviation bird strikes. Experimental bird tissues were subjected to severely damaging conditions to determine if DNA could be extracted from these samples. In addition, DNA and feather microscopy databanks were created from the species classified as being the highest risk for strikes to provide reference data to compare against unknown samples. Finally, a DNA sampling kit was created and distributed widely to aerodromes across Australia for collection of material from unknown strikes for DNA analysis. Results of experimental bird tissue experiments showed the most detrimental conditions for DNA were to leave a sample at room temperature for 7+ days. DNA was successfully extracted from all strike samples collected with sampling kits then returned to the laboratory and positive identifications were able to be made to species level in the majority of cases. Interestingly, it was found that attempts at visual species identification were often incorrect and that the putative high-risk species were only responsible for 27 per cent of the unidentified strikes. In general, we found DNA identification of strike species to be a reliable method for identifying the species involved in collisions and conclude that it would be a useful addition to the methods already employed to identify wildlife strikes at civilian aerodromes.

This paper provides a preliminary review of options for making marine pilot transfers safer, as the traditional method of transferring via a pilot ladder has resulted in fatalities and serious injuries. The project included a review of the literature, interviews with pilots and a survey of methods used in other industries for similar tasks. Results indicate that the safety of the current transfer arrangement would be increased through strategies including ladder design improvements, use of fall protection systems and/or use of mechanical personnel elevation systems. Each of these strategies requires further investigation to determine the design criteria best suited to the task, the pilot population and the marine environment. The report also identifies a number of additional initiatives requiring review that contribute to reducing the risks in the pilot transfer task.

The primary aim of this study was the development of a set of normative data that captured the performance of a sample of general aviation pilots during a simulated flight from Wagga Wagga to Bankstown via Canberra, Goulburn and Mittagong. A secondary aim was to consider the impact of pilot qualification on the performance of pilots during the five legs of the flight.

Pilots were issued a completed flight plan and all the relevant documents necessary to complete the flight, including weather information, maps, and an aircraft checklist. A total of 34 pilots were recruited to undertake the flight and the exercise was conducted as it would be expected to occur within the operational environment. The experimenter acted as the Flightwatch operator and air traffic controller where necessary, and recorded the details of the flight.

Data pertaining to in-flight performance were recorded at a number of different levels of analysis, the first of which was pilots' own self-reports of their performance. Pilots' performance was also rated by an observer, and assessments were made on a number of different dimensions including the accuracy with which the aircraft was controlled, the accuracy of the track flown, the accuracy in maintaining the prescribed altitude, the level of fatigue management, and the appropriateness of the communication. The final level of analysis involved objective data that were recorded each second that the simulator was in operation. For each of the five legs of the flight, a set of geographic boundaries were identified and representative data that occurred with these boundaries were summarised using measures of central tendency¹.

In relation to the self-report data, pilots considered their performance in the flight simulator poorer than their performance in general. This may be explained by the difficulties that some pilots perceived in exercising control over the simulated aircraft. Indeed, of the eight dimensions assessed, aircraft control was associated with the lowest rating during the simulation. However, it should also be noted that relatively lower ratings were recorded for other variables including fuel management, fatigue management, scanning, and decision-making.

The observations of pilot performance revealed differences between perceived behaviour during the five legs of the flight. Specifically, performance during leg 5, the last leg, tended to be rated at a level consistently lower than performance during the preceding legs. Comparative analyses using pilot qualification as a between-groups factor failed to explain the basis for this difference in perceived performance.

The differences between the perceived performance of pilots in leg 5 and perceived performance during the preceding legs of the flight were further examined using the data recorded by the flight simulator. While differences were anticipated for variables such as altitude, it appeared that performance deteriorated on a range of variables, including the mean range of the heading and the mean range of the pitch angle of the aircraft. The variability in performance during the final leg of the flight could not be explained on the basis of pilot qualification, and suggests that other factors may be impacting on performance. It was considered that these factors might include the impact of fatigue and/or the impact of the demands in conducting a stepped descent to avoid violations of controlled airspace during the approach to Bankstown airport.

Overall, the data acquired in the present study represent a useful normative dataset against which the performance of pilots can be assessed in the future. As expected, there is a significant level of variability in the performance of pilots who conducted the simulated approach. This variability was most evident during the final stage of the flight when the demands on pilots were most acute and when the impact of fatigue was most likely to occur. This represents an avenue for future research and development.

1. Measures of central tendency are statistical summaries of a set of data. The most common measure of central tendency is the mean (average), followed by the median (the middle score in a series of rank-ordered data), and the mode (the most frequently occurring result).

While improper execution of the flare manoeuvre has been implicated in many landing incidents, very few human factors studies appear to have examined this problem. Our flight simulation study examined three different visual strategies that pilots could use to time the flare. On each trial, non-pilots, student pilots or private pilots were required to judge either:

(i) their time-to-contact with the ground; or

(ii) an idealised time to initiate the flare.

Our data provided some support for the hypothesis that pilots initiate the flare when their perceived time-to-contact with the ground reaches a critical value. Pilot performance was generally superior to non-pilot performance. However, both pilots and non-pilots were found to demonstrate flare timing biases during impoverished visual conditions (i.e. reduced depth cues) - indicating that strategies based on perceptions of environmental distance and/or critical runway angle must also have played a role. Importantly, very accurate timing judgments were possible with richer visual displays (i.e. additional depth cues) that provided performance feedback. Thus, we conclude that entry-level flight simulators can be used for flare timing training if certain minimum visual display conditions have been met.

Aircraft maintenance errors are estimated to be involved in 12% of airline accidents worldwide. Records maintained by the Australian Transport Safety Bureau (ATSB) indicate that 4.5% of Australian aircraft accidents involve maintenance deficiencies. Human error in aircraft maintenance is poorly understood and has not been the subject of previous studies in Australia. In late 1998 the Bureau of Air Safety Investigation (now ATSB) distributed a survey to Licensed Aircraft Maintenance Engineers (LAMEs) in Australia. The survey was designed to identify safety issues in maintenance, with a particular emphasis on the human, or nontechnical aspects of the job.

The survey provided LAMEs with the opportunity to describe occurrences that had the potential to threaten the safety of an aircraft, or the safety of maintenance workers. Six hundred and ten occurrence reports were reported via the survey. In most cases the reported events resulted in relatively minor consequences. The most common form of occurrence was one in which an aircraft system was activated in an unsafe manner during maintenance. The next most common form of occurrence involved the incomplete installation of components. Over 95% of the occurrences involved the actions of people. The most common forms of human error contributing to the events were memory lapses and procedure shortcuts. The contributing factors most frequently listed by survey respondents were time pressure, equipment deficiencies, inadequate training, coordination difficulties and fatigue. There was evidence that the frequency of safety occurrences fluctuated throughout the 24 hour day and that the early hours of the morning were times of particular risk for maintenance occurrences.

Several safety deficiencies were identified in the course of this study. These included: a current lack of programs to limit the extent of fatigue experienced by maintenance workers; a lack of recurrent training for licenced aircraft maintenance engineers; a need for maintenance personnel to be trained in crew resource management skills such as communication and the management of production pressures; a widespread blame culture in aircraft maintenance which discourages personnel from officially reporting incidents; and the simultaneous maintenance of critical multiple redundant systems, which can make the consequences of errors more serious. The report concludes with recommendations directed at these issues.

The purpose of this publication is to provide an overview of level crossing accident fatalities in Australia. The information provided is based on unpublished data obtained from the Australian Bureau of Statistics but responsibility for the analyses presented here rests solely with the ATSB.

Many factors contribute to an airline's safety record, some external to the organisation and others internal. An important internal contribution comes from the manner in which the company's flight operations are managed. This study addresses the organisational factors impinging on an airline's safety outcome that are subject to influence by managers in their flight operations divisions. Particular attention is given to evidence of the concept known as 'institutional resilience'.

Twelve major airlines in Australasia and South East Asia participated in the study. The study used a mixed method approach, incorporating both qualitative data (interviews) and quantitative data (audit). The qualitative approach used in-depth interviews, conducted with 36 senior managers in the twelve airlines. The quantitative approach comprised a self-reported audit of organisational management arrangements within each airline. The audit was conducted by means of a questionnaire sent to one senior manager in each airline. Eleven questionnaires were returned.

This report deals with the analysis of results from the audit.

The scope of the audit was determined by both the framework adopted for the study and by information gained during the preceding 36 interviews. The framework of analysis has six-parts: human factors, culture, safety management systems, benchmarking, and theory of high reliability and institutional resilience.

The results show both significant similarities and important differences between the airlines. Attention is given to differences between domestic and overseas airlines. The similar outcomes are useful as a normative guideline on the way airlines should address their management of safety. The differences provide a guide to further development by both airlines and researchers. The findings are discussed in detail at Section 5 of this Report.

The study identifies three areas suitable for further research. The first relates to further development of reactive and proactive measures that can indicate the state of an airlines' 'safety health'. When used in an appropriate combination, such measures should indicate changes in intrinsic safety levels and facilitate the prioritisation of remedial action. The next area builds on the first by investigating the development of a checklist, similar to the Checklist for Assessing Institutional Resilience (CAIR). A suitable checklist must appeal to the airlines in terms of its practical application. The third area is development of a process to improve the reporting rate of flight crew error.

Cranfield University in the United Kingdom, working in collaboration with Virgin Blue Airlines in Australia, applied to the Australian Transport Safety Bureau for an aviation safety research grant in 2004. The grant was awarded to support a two-phase research project into evacuation commands used by cabin crew in managing passengers during evacuations. The first phase was a best practice forum and survey, supported by members of the Asia Pacific Cabin Safety Working Group of the Australian Society of Air Safety Investigators, to establish the commands, policies and procedures currently in use among Australian and Asian operators. The results of this survey informed the development of the research aims for the second phase of the project.

The second phase involved both survey and experimental work, with members of the public participating as passengers. Four groups of up to 40 members of the public were recruited to take part in this phase of the research; all participants completed questionnaires asking for demographic information. In addition, participants were asked about the commands that they would expect to hear in a range of safety-related and emergency situations. The data from these questionnaires were used to explore passenger expectations and comprehension of emergency commands. The results indicated that participants generally had a low understanding of why they might be required to take certain actions in emergency situations. This suggested that it is important that operators take passenger expectations and comprehension into account when devising evacuation commands.

The same participants then took part in one of four sessions of four evacuation trials at Cranfield University in the United Kingdom. In each test session, two evacuations were from the Boeing 737 cabin simulator, and two from the Large Cabin Evacuation Simulator (LCES). The aim of the experimental tests was to investigate the effectiveness of selected cabin crew commands in managing passengers during evacuations. All trials were video-recorded in order that footage from the trials could be time-coded and analysed.

In the Boeing 737 simulator, the first aim was to investigate the use of active and passive safety briefings. Two groups of participants received an active safety briefing, in which the cabin crew generated a high level of interaction in briefing passengers on safety procedures. On the other two test days, participants received a passive safety briefing. Research in cognitive psychology had suggested that actively-briefed passengers would be better able to recall and act on that information if (or when) the need arose. The Boeing 737 evacuation trials were also used to investigate the extent to which having the cabin crew provide passengers with additional relevant instruction would enhance evacuations in poor visibility conditions. The results indicated that while the active safety briefing did not improve evacuation times, passengers rated this briefing as significantly more useful and helpful, and stated that the active safety briefing significantly improved their confidence in evacuating the cabin.

In the LCES, the first aim was to investigate the influence of crew commands during evacuations from a wide-bodied cabin simulator, given that the exits and slides on such aircraft types are typically rated for a dual-lane flow¹. Dual-lane flows significantly increase evacuation rates, and yet results from Phase I showed that many operators do not require their cabin crew to command passengers to move through exits two at a time.

The second aim of the LCES tests was to manipulate the extent to which participants could see the cabin crew during the early stages of an evacuation. These tests aimed to gauge the effectiveness of gestures, eye contact and other non-verbal communications used by the cabin crew in managing passengers.

The results showed that evacuations without dual-lane flow commands were faster, but more disorganised. With a larger passenger load, dual-lane flow commands could be useful for managing the evacuation in a more orderly and less congested fashion. Visibility had a pronounced effect. The half-height bulkheads meant that cabin crew gestures could actually be seen be passengers, who rated the crew's non-verbal communication as significantly more useful in the high-visibility evacuations. The high visibility also gave passengers something to aim for in the evacuations - they had sight of the exit. Hence, it was significantly easier for them to move out of their seats and along the aisles in the half-height bulkhead conditions.

The results of this research could provide useful input to cabin crew training (initial and recurrent), to the design of best practice evacuation procedures and commands, and also potentially to the design of bulkheads and cabin configurations. In addition, the results could assist in designing safety information which is more closely aligned with passenger expectations, and therefore more likely to be effective.

1. The over-wing exits in a typical wide-bodied jet aircraft are full size doors, which allow for dual-lane flow, rather than the smaller push-out exits typical of narrow-bodied jet aircraft.

Fire contributes to aircraft accidents and many fatalities. The growing use of polymer composite materials in aircraft has the potential to increase the fire hazard due to the flammable nature of the organic matrix.

The polymer composite most often used in the external structures of aircraft is carbon/epoxy, which is a flammable material that easily ignites and burns when exposed to fire. A large percentage of the cabin interior of wide-bodied passenger aircraft is made using composite materials, mostly glass/phenolic. Phenolic composites have good flammability, but newer materials are being developed that offer the promise of increasing the fire safety of aircraft cabins. In fact, a large number of new composite materials are being developed for cabins and external structures that have the potential to increase the fire safety of aircraft, but a detailed analysis of the fire performance of these materials against conventional materials now used in aircraft has not been performed. Such an evaluation will provide a clear indication of the potential improvements in fire safety by using new fire-resistant composites in aircraft.

This report assesses the fire hazard of current and next-generation polymer composites for aircraft and identifies those materials with improved flammability resistance. A comprehensive review of the scientific literature was performed to develop a database on the fire properties of a large number of polymer composite materials. For both aircraft cabin materials and aircraft structural materials the following fire properties were considered in the determination of fire safety: time-to-ignition, limiting oxygen index, peak heat release rate, average heat release rate, total heat release, flame spread rate, smoke, and combustion gases. The data is presented as performance tables which rank the composite materials in order from best to worst.

The composite most often used in pressurised aircraft cabins is glass/phenolic, and the database shows that this material has excellent fire reaction performance¹ and that very few next-generation composites display superior properties. The most used structural composite is carbon/epoxy, and this material has poor fire resistance and can pose a serious fire hazard. A number of advanced structural composites with superior fire properties are identified, including materials with high temperature thermoset polymer, thermoplastic or inorganic polymer matrices.

1. Fire reaction performance is a measure of a material's resistance to combustion as determined by a range of parameters such as time-to-ignition, heat release rates, limiting oxygen index, etc.

The ATSB Annual Review 2001 documents ATSB's achievements and safety activities from 1 July 2000 to 30 June 2001 and outlines its business planning for 2001-2002.

Producing the annual review is in line with a recommendation of the McGrath report into the former Bureau of Air Safety Investigation released in August 1999 to improve the transparency and accountability of the Bureau.

Creation of the ATSB on 1 July 1999 brought together the safety investigation, statistical analysis, research and safety program management of the Commonwealth's transport safety role in one multi-modal agency within the Department of Transport and Regional Services. ATSB intends to prepare an annual review to provide all stakeholders with an overview of its activities and safety in each transport mode. This first review covers a range of topics including:

• ATSB's safety mission, values, organisational structure, operational environment and internal management;
• key ATSB safety results by transport mode;
• a statistical overview of safety in the transport modes of road, rail, aviation and marine;
• ATSB participation in Parliamentary inquiries; and
• ATSB's performance against the measures in the 1999-2000 Portfolio Budget Statements.