Since 1970 fatalities resulting from accidents between road vehicles and trains at level crossings have reduced by about 70 per cent. However, recently there has been an increasing number of accidents involving heavy road vehicles.

Between April 2006 and December 2007, the ATSB investigated 12 level crossing accidents. Of these 12 accidents, nine have involved heavy road vehicles, four of which have been collisions with long distance passenger trains. In addition, during the same period State authorities have investigated a further three significant accidents between heavy vehicles and passenger trains.

These accidents have cost the lives of 19 people, 13 on board the trains and six occupants of the road vehicles. In addition, over 60 people have been injured and the damage bill is estimated at well over $100 million.

Although fatalities and injuries resulting from accidents at railway level crossings are only a small proportion of the total fatalities and injuries that occur on Australian roads each year, railway level crossing accidents, particularly when they involve heavy road vehicles, have the potential to be catastrophic.

Heavy road vehicles such as road-trains and larger freight trains have become the norm in Australia for the good reason that they are an efficient way to transport goods over long distances between our metropolitan and regional centres. However, with the increased size comes an increased consequence in the event of a level crossing collision. It used to be somewhat rare to hear of a train derailing or of significant casualties on board the train as a result of a collision with a road vehicle. This is not the case today.

Some recent accidents have involved significant loss of life, the worst case being the tragic accident at Kerang when a semi-trailer collided with a Melbourne-bound passenger train on 5 June 2007. Eleven people were killed and 20 injured in this accident.

Another major collision between a B double truck and a freight train occurred at Lismore, Victoria on 25 May 2006. This accident resulted in the death of the truck driver and an estimated damage bill in excess of $30 million.

Maintenance is essential to aviation safety, yet improper maintenance contributes to a significant proportion of aviation accidents and incidents. This is because a small percentage of maintenance tasks are performed incorrectly or are omitted due to human error. Examples include parts installed incorrectly, missing parts, and the omission of necessary checks. While precise statistics are unavailable, it is likely that the great majority of maintenance errors are inconsequential, however, a small proportion present significant safety threats. In comparison to many other threats to aviation safety, the mistakes of maintenance personnel can be more difficult to detect, and have the potential to remain latent, affecting the safe operation of aircraft for longer periods of time.

While acknowledging that maintenance personnel are responsible for their actions, it must also be recognised that, in many cases, the errors of maintenance technicians are the visible manifestation of problems with roots deep in the organisation. A careful examination of each error, combined with a preparedness to inquire into why the error occurred, can help to identify underlying organisational problems. Effective countermeasures to maintenance error require a systemic approach, not only towards issues at the level of the technician and their work environment, but also to organisational factors such as procedures, task scheduling and training. Some countermeasures to the threat of maintenance error are directed at reducing the probability of error through improvements to training, equipment, the work environment and other conditions. A second, complementary, approach is to acknowledge that despite the best efforts, it is not possible to eliminate all maintenance errors, and countermeasures must be put in place to make systems more resilient to those residual maintenance errors that are not prevented.

Aviation organisations are increasingly introducing safety management systems (SMS) that go beyond legal compliance with rules and regulations, and instead emphasise continual improvement through the identification of hazards and the management of risk. The activities involved in managing the risk of maintenance error can be appropriately included within the SMS approach. Key activities include internal incident reporting and investigation systems, human factors awareness for maintenance personnel, and the continual identification and treatment of uncontrolled risks.

On 20 February 2009, this report was updated to include a list of resources and further reading on page 34.

This report analyses birdstrikes reported to the Australian Transport Safety Bureau between 2002 and 2006. In Australia, over the last five years, the number of birdstrike occurrences reported annually to the Australian Transport Safety Bureau (ATSB) has risen from approximately 750 in 2002 to 1,200 in 2006. The report includes bird and bat strikes that occurred in Australian territory involving VH- and overseas registered aircraft. It excludes strikes involving non VH-registered Australian aircraft and those involving VH-registered aircraft that occurred overseas. Birdstrikes were analysed by year, month, phase of flight, type of operation, record source, effect on flight, time, aircraft damage, injuries, the nature of occurrence reports, flight disruption, aircraft movements, aircraft size, ingestion, bird size, species, and location. Location data are presented for major aerodromes, General Aviation Airport Procedures aerodromes and regional aerodromes. The report tables birdstrikes and aircraft movements, as well as species struck and species causing damage.

Birdstrike reporting was found to have almost doubled over the reporting period. There have been three injuries, but no fatalities. Around seven per cent of birdstrike events resulted in damage, and double-engine ingestion was recorded for eight of 5103 birdstrike occurrences. Birdstrike events vary by location, and rates of birdstrike events at aerodromes are only indicators of the effectiveness of control measures.

The ATSB has changed the way in which aviation statistics are presented. This report represents the first in an ongoing series of reports provided in the new format. The report encompasses a rolling 10-year reporting cycle and replaces all individual spreadsheets previously available.

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

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

In 2007 the Australian Transport Safety Bureau (ATSB) produced the inaugural edition of Australian Aviation Safety in Review as part of the ATSB's role to enhance public awareness of aviation safety. The Review has been developed to provide a readily accessible analysis of the Australian aviation sector, with a strong focus on safety trends. This publication covers all major categories of aircraft operations, from regular public transport (RPT) to general aviation (GA), and includes some information about sports aviation.

Demographic and activity data on Australian aviation is provided in order to provide a context within which to examine accident trends. Accidents are presented both in terms of the raw number of accidents and as rates per 100,000 hours flown, to enable a comparison between operational categories. The latest year for which flying hours are available is 2006. Accordingly, this edition of the Australian Aviation Safety in Review covers the five calendar years 2002 to 2006, offering insights and information about key trends and emerging issues.

This is the second edition of Australian Aviation Safety in Review and the ATSB intends to update this report in the future as a means of informing both the aviation community and the wider public about Australian aviation accident and activity trends.

The quality of a safety investigation's analysis activities plays a critical role in determining whether the investigation is successful in enhancing safety. However, safety investigations require analysis of complex sets of data and situations where the available data can be vague, incomplete and misleading. Despite its importance, complexity, and reliance on investigators' judgements, analysis has been a neglected area in terms of standards, guidance and training of investigators in most organisations that conduct safety investigations.

To address this situation, the Australian Transport Safety Bureau (ATSB) developed a comprehensive investigation analysis framework. The present report provides an overview of the ATSB investigation analysis framework and concepts such as the determination of contribution and standard of proof. The report concludes by examining the nature of concerns that have been raised regarding the ATSB analysis framework and the ATSB's consideration of these concerns.

The ATSB believes that its investigation analysis framework is well suited to its role as an independent, no-blame safety investigation body. It is hoped and expected that ongoing development and provision of information about the framework can help the safety investigation field as a whole consider some important issues and help develop the best means of conducting safety investigations to enhance future safety.

The ATSB released this report in June 2008. Since that time, the ATSB has received comments regarding the technical accuracy of the removal of particles from high efficiency particulate air filters (page 6 of the report). This report has been amended accordingly and contains an additional reference for readers on page 10.

Every year, an increasing number of people undertake air travel. Whether for business or pleasure, these journeys should be safe and enjoyable. However, there is continuing public concern about whether, or to what extent, aircraft cabins represent an increased risk of transmission of infectious disease. The purpose of this report was to review the current literature on the potential risk of disease transmission within an aircraft cabin.

The evidence suggests that passengers' health is not greatly at risk through air travel and widespread infections are unlikely. Although there have been cases of infectious disease transmission in aircraft cabins, there is evidence that such transmission was primarily due to the crowding together of a large variety of people in a confined space, not specifically due to aircraft cabin conditions. This suggests that the risk of transmission within an aircraft cabin is no greater than in other crowded and confined spaces, provided circulation and filtration systems are working properly. Perhaps of greater concern is the opportunity for infection to spread in airport terminals, where passengers who are travelling to or from many destinations are gathered together.

The increase in international travel has also heightened the risk for the global spread of infectious diseases. It is not possible to predict when the next pandemic will occur or how long it will last but many health officials think that it's only a matter of time. Although the increase in international air travel could assist with the spread of a future influenza pandemic, the aviation industry will also play a critical role in mitigating the consequences.

For many decades, fibre composites have been replacing traditional aluminium structures in a wide variety of aircraft types. From the first all-composite kit plane released in 1957, composites are widespread today in commercial aircraft and many other aircraft types. This is due to the cost and weight savings that materials such as glass/phenolic and carbon/epoxy offer aircraft manufacturers over aluminium, while maintaining or surpassing its strength and durability.

This study provides an overview of fibre composite use in aircraft and the issues associated with its use, with a focus on aircraft operating in Australia that contain these materials. There are almost 2,000 aircraft on the Australian civil register made of, or containing, fibre composite materials. This includes most of the mainline jet fleet, effectively all sailplanes and gliders, many popular general aviation aircraft, and a third of the growing amateur-built aircraft category.

There is a lot of conflicting or incorrect information in the aviation community about the safety and capability of fibre composite materials. Composite structures behave very differently under normal loads than equivalent metal structures. Fatigue and corrosion have been proven through trials of composite repair patches to be much less prevalent in composites compared with metals. Subsurface damage such as delamination however can go undetected for long periods and result in sudden catastrophic failure. It is important that operators of fibre composite aircraft be aware of correct detection and repair procedures for the unique types of damage that occur to composites.

First responders involved in post-crash cleanup operations have expressed concerns about the long-term effects from exposure to carbon fibres released from burning composites. Fibre dust can pose an inhalation risk similar to asbestos. Released fibres or splinters are needle-sharp, and can cause skin and eye irritation. In the event of a post-crash fire, smoke and toxic gases are also released from decomposing composites, presenting further health risks.

Financial year 2007-08 was in many respects a watershed year. In road safety, the November election of the Rudd Government led to the move of road safety from the ATSB to the Department proper from the end of March 2008 to better align with the new Government's priorities. While I was proud to chair the National Road Safety Strategy Panel from 1999 to 2008, the establishment of a higher level Commonwealth/State body holds the promise of making further gains in reducing the nation's unacceptably high road toll. However, I was personally sad to lose the road safety branch led by Joe Motha and John Goldsworthy and their dedication and professionalism from the ATSB and am grateful for all they did while in the Bureau.

In surface safety investigation, we exceeded our output targets and are well positioned to improve future timeliness of reports. I was particularly pleased with the final Pasha Bulker marine investigation report and the rail investigation report at Ban Ban Springs and associated work on the safety of very large trucks at level crossings. I thank Peter Foley in particular for his leadership in surface safety.

Internationally, we were instrumental in gaining International Maritime Organization approval of a new marine investigation code and the role of Patrick Hornby deserves special commendation. Our contribution to the Government 'ITSAP' assistance program to Indonesia included substantial input led by Alan Stray in the finalisation of the Indonesian National Transportation Safety Committee investigation reports on fatal 737 accidents involving Garuda and Adam Air. Alan and Kerryn Macaulay also ensured that the ATSB's part of the 2008 ICAO state audit was very positive. A wide range of other ATSB outputs, including aviation research, technical analysis, occurrence notifications, and IT, benefited from Kerryn's leadership.

The greatest organisational pressure during 2007-08 was faced by the aviation investigation branch led by Julian Walsh. It is very difficult to select up to 80 investigations from the more than 8,000 accidents and incidents reported annually and inevitably parties associated with occurrences on the margins may not agree with the selection. There are also competing priorities between investigating fatal general aviation accidents to a level sought by state and territory coroners (and the further resources needed in any ensuing inquests), and doing more investigation of fare-paying passenger regular public transport incidents where there may be more future safety value. There is often a further trade-off between numbers of new investigations and timeliness. I am extremely grateful for Julian's leadership in managing, with his team leaders, in this environment. The 'Miller Review' was a further pressure that required substantial ATSB input. The new Government's announcement, through portfolio Minister the Hon Anthony Albanese, of an aviation Green and White Paper process was seen as a significant opportunity and warmly welcomed by the ATSB.

I also wish to publicly thank the ATSB training manager, Colin McNamara, for volunteering to coordinate the ATSB's central office move from 15 Mort Street to 62 Northbourne Avenue. His planning during 2007-08 led to a smooth move in September 2008.

Kym Bills, Executive Director

The objective of the project is to analyse GPWS warnings in Australia with a view to addressing ICAO steps (e) Investigation of GPWS warnings and (f) Reduction of unwanted warnings, of the circular AN11/1.1.1993/61.

CFIT accidents are the most severe aircraft accidents. These kinds of accidents occur when an otherwise airworthy airplane is inadvertently flown into the ground or water. The number of fatalities per accident is extremely high as compared to any other type of accident. They also generally result in complete destruction of the airplane. If CFIT accidents were to be completely prevented, approximately half of the worldwide fatalities in aircraft accidents would also be prevented. CFIT accidents have a high leverage for safety improvement.