Maintenance incidents contribute to a significant proportion of worldwide commercial jet accidents, yet until recently, little was known of the nature of maintenance incidents and the factors which promote them.

In face-to-face interviews, maintenance technicians were asked to report examples of maintenance incidents which they had experienced first-hand. Eighty-six incident reports were recorded.

Human factors were involved in most of the reported incidents, with workers on duty between the hours of 0200 and 0400 having a greater chance of having an incident than workers on duty at other times of the 24-hour clock. The frequency of incidents increased as the shift progressed up to the second-last hour, after which the frequency of incidents diminished.

For those incidents which had the potential to affect the airworthiness of an aircraft, difficulties with procedures emerged as the most significant factor. This included misunderstandings and ignorance of procedures.

For those incidents which had the potential to affect the health and safety of workers, difficulties with tools and equipment emerged as the most frequent factor.

The majority of the human errors involved in incidents were rule-based mistakes, many related to mistaken assumptions. Absent-minded slips and lapses were involved in approximately one-third of the incidents.

The final section of the report contains suggested safety actions, intended firstly to reduce the frequency of human error and maintenance incidents and secondly, to reduce the consequences of any such errors which do occur.

Human error is recognised as an important issue in fields as diverse as medicine, mining and shipping, and to some extent aviation.

Although the human element has long been recognised as important in the cockpit, its role in aircraft maintenance has been largely overlooked.

According to Boeing figures 12% of major aircraft accidents involve maintenance, and 50% of flight delays in the US are caused by maintenance errors.

In response to a worldwide lack of information on the issue, in late 1998 the Bureau distributed a safety survey to all licensed aircraft maintenance engineers in Australia.

This survey was the first such study undertaken anywhere in the world.

In addition to collecting incident reports, part of the survey used a technique pioneered by road safety researchers in the UK, where recipients were asked to report minor errors and shortcuts.

The focus was on learning how common these events are relative to one another, rather than obtaining precise event frequency information. In that regard there was no specific time frame specified in the survey form in which the event could have occurred.

Most of the errors reported by the respondents constitute 'near misses'. However, it is possible to anticipate how more serious events could occur by gathering this information.

The ATSB considers that the issues identified in the survey are not specific to Australia but will be of use to safety agencies around the world.

Based on early information from the survey the Bureau previously published in Asia-Pacific Air Safety articles that identified a number of recommendations:

1. the need for refresher training for aircraft maintenance engineers
2. the need to remove barriers which discourage aircraft maintenance engineers from reporting incidents
3. the need for fatigue management programs
4. human factors training for management and engineers, and
5. minimisation of the simultaneous disturbance of multiple or parallel systems, such as both engines on twin-engine aircraft.

The recent article on the survey on the ATSB Supplement to Flight Safety Australia March-April 2000 also included advice directed to aircraft maintenance engineers concerning memory lapses, pressure, fatigue and coordination difficulties.

The survey is part of a broader study of aircraft maintenance operations, which is anticipated, will lead to identification of targeted safety measures.

The ATSB has come a long way since its creation on 1 July 1999. Legislation, training and IT systems have all been upgraded. The ATSB has an increasingly national and international reputation for independent safety material. This is reflected in the almost 800,000 new visitors to the ATSB website which also had more than 30 million 'hits' in 200607, and in multiple articles in such publications as the prestigious US-based Flight Safety Foundations AeroSafety World.

During 2006 - 07, the ATSB finalised its complex investigation into Australian civil aviation's worst accident since 1968, the 15-fatality aircraft accident near Lockhart River, Queensland on 7 May 2005. The 500-page final report released on 4 April 2007 identifies important safety issues to enhance future aviation safety relating to the crew, the operator, regulatory oversight and instrument approach chart design. Three ATSB factual reports, a research report and ten safety recommendations were released during the course of the almost two-year investigation. A further ten safety recommendations were issued with the final report, which also utilised an enhanced ATSB investigation and analysis methodology. Among other coronial inquests, the ATSB assisted with the inquest into the Lockhart River accident by the Queensland State Coroner which included a month of hearings on Thursday Island and in Brisbane. The Coroner reported on 17 August 2007.

During the year the Bureau released 80 final aviation investigation reports, 19 aviation safety recommendations, 10 aviation safety research reports and five research grant reports. The ATSB also cooperated with the Indonesian National Transportation Safety Committee (NTSC) in the investigation of the Garuda Airlines Boeing 737-400 accident at Yogyakarta Airport on 7 March 2007 in which 21 died, including five Australians, and 12 were seriously injured. ATSB assistance included an on-site team comprising a Deputy Director and two senior investigators, flight recorder analysis in Canberra, and the drafting of preliminary and final reports.

In April 2007 the Bureau introduced a new Safety Investigation Information Management System (SIIMS) aviation database which will be extended to rail and marine in 2007-08. SIIMS was developed using the $6.1 million committed by the Australian Government in the May 2004 Budget, and was within time and budget.

In marine, the ATSB released 14 investigation reports, issued 38 safety recommendations and continued an education campaign on commercial fishing vessel safety. International success included ATSB coordination and facilitation of recent amendments to the Code for Investigation of Marine Casualties and Incidents as a member of the IMO Flag State Implementation Subcommittee. The ATSB also assisted with the inquest into the loss of the Immigration vessel Malu Sara with five fatalities in the Torres Strait.

The ATSBs rail safety investigation team released nine final reports and 39 safety recommendations under the Transport Safety Investigation Act 2003 (TSI) which included a number of level crossing accidents. In June 2007, the ATSB published jurisdiction regulators rail safety occurrence data in eight key categories covering the period January 2001 to December 2006. Further improvements in rail safety data are being sought through a process coordinated by the National Transport Commission.

The ATSB is continuing its commitment to training its investigators through accredited Diploma of Transport Safety Investigation. In 200607, 12 staff completed the TSI Diploma with 13 progressing through the required coursework and mentoring.

In March 2007 I completed my term as Chairman of the International Transportation Safety Association (ITSA), which includes major independent transport safety investigation bodies from around the world. ITSA has been revitalised and has grown to include the UK, Japan and Norway. France and South Korea are potential new members.

The ATSB continued to support Ministers with road safety advice and coordinated with other jurisdictions to develop the National Road Safety Action Plan for 2007 and 2008, which was approved by Ministers of the Australian Transport Council. While the challenges in road safety are immense, progress is being made in jurisdictions and through other stakeholders. It has been my privilege to chair the National Road Safety Strategy Panel since 1999 and work with such dedicated officers as ATSB General Manager Joe Motha and Team Leader John Goldsworthy and senior staff including Chris Brooks.

In 2006-07 the ATSB released 25 road safety research and statistical publications including a report on transport injuries amongst Indigenous people. The Bureau also helped organise an Indigenous road safety forum in October 2006. Work continued in preparation for the major novice driver research trial in New South Wales and Victoria which the Australian Government is supporting. Partners are scheduled to finalise the curriculum and conduct pilot testing before the end of 2007.

All of the achievements made in 2006-07 and on an ongoing basis are the result of the dedication of ATSB professional officers. For this untiring service, I salute them all. Most have made major personal sacrifices to make a difference for future transport safety. I particularly recognise my direct report colleagues: Peter Foley, Kerryn Macaulay, Joe Motha, Alan Stray and Julian Walsh. The investigator-in-charge of the Lockhart River investigation, Greg Madden and his team also deserve special praise.

A review of existing Commonwealth, State and Territory legislation relating to the transport of dangerous goods by rail, was undertaken. The review provides an overview of the status, coverage and adequacy of existing rail dangerous goods transport legislation. The review also examines options for the development of a nationally uniform regulatory regime for rail dangerous goods transport operations. Issues relating to inter-modal harmony with the road transport sector, and legislative options to achieve uniformity are also discussed. The review concludes that a nationally uniform rail dangerous goods regulatory regime, harmonised with the road transport sector, should be given a high priority due to safety, transport efficiency and economic reasons.

The details of 75 fatal aeroplane accidents were extracted from the BASI database. The largest proportion (36%) of the accidents occurred on private/business flights. The three most frequent first occurrences in accidents were loss of control; collision with terrain (control unknown); and wirestrike. Most accidents had more than one contributing factor. Over 70% of the accidents involved pilot factors. The most common pilot factors related to poor judgement and decision making.

In recent years, BASI has recognised that while pilot factors are of great importance, accidents frequently have their origins in systemic or organisational failings.

With the creation of the ATSB in July 1999, followed by the enactment of the Transport Safety Investigation Act (TSI Act) in 2003, Australia had for the first time a national body with a mandate for professional and independent rail safety investigations.

In its relatively short existence, the ATSB's rail safety unit has had a significant influence on rail safety in Australia. In particular, it has been instrumental in fostering an approach that emphasises the importance of system safety, rather than just focusing on the mistakes of operational personnel.

Other notable achievements of the ATSB in rail investigations have included raising awareness within the rail industry of the importance of modern health and safety standards for operational personnel, and highlighting specific accident types. These include accidents due to poor communications, signalling difficulties, derailments such as through dynamic track and rolling stock interactions, fatigue, and level crossing collisions.

This report tables rail safety occurrence data by state and territory between January 2001 and December 2007. Data is adjusted annually 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 reporting period and publication of these data. Previous versions of this publication should be discarded. These data are presented as counts and normalised using kilometres travelled and number of track kilometres. Data presented in this report conforms to Standard No. ON-S1: Occurrence Categories and Definitions. This report excludes tram and light rail or monorail operations.

On 2 June 2008, the ATSB was notified by the South Australian Department for Transport, Energy and Infrastructure that the data originally published in May 2008 for South Australian running line collision with road vehicle incidents prior to 2005 included collisions with trams while running on roadways. These incidents have been removed from Table 13 in this amended version of the report.

This report tables rail safety occurrence data by State and Territory between 1 January 2001 and 31 December 2008. Data is adjusted biannually to reflect new information that comes to light during the reporting period. There is a lag period of approximately three to four months between the end of the six-monthly reporting period and publication of this data. The data is presented as counts, and normalised using kilometres travelled and number of track kilometres.

Please contact individual jurisdictions for media enquiries.

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Aircraft depressurisation events are rare, but they can occur with little or no warning. The faster you put on your oxygen mask, the better the chance that you will stay safe and remain capable of helping children and others. Reading this safety bulletin will help ensure that you can recognise and appropriately react to an aircraft depressurisation if one should occur.

Why are aircraft pressurised?

Modern aircraft are designed to fly at high altitudes. (For example, large jet aircraft normally cruise at an altitude of 28,000 – 35,000 ft). This is because aircraft consume less fuel and can fly in relatively smooth air, avoiding bad weather and turbulence. However, the human body is not designed to survive at such high altitudes so the air pressure inside the cabin needs to be controlled.

The air pressure inside the cabin cannot be kept the same as the ambient air pressure at ground level as doing so would put excessive stress on the aircraft. Therefore, air pressure altitude inside the cabin (as measured by the equivalent outside altitude) gradually rises from take-off to a maximum of 8,000 ft during the cruise. During the descent to the destination airport, the cabin pressure altitude is gradually reduced to match the ambient air pressure of the airport. Without a fully functional pressurised cabin, passengers and crew need to use oxygen systems at the altitudes typically attained during cruise.

What is depressurisation?

Depressurisation, also called decompression, is the reduction of atmospheric pressure inside a contained space such as the cabin of a pressurised aircraft.

This report provides aviation accident and incident, collectively termed occurrence, data for the period 1 January 1998 to 30 September 2008. 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, and is current as at 30 September 2008.

The data will be adjusted quarterly to reflect new information received during the reporting period.