ATSB releases Jumperkine freight train collision preliminary report.

Functionality of locomotive braking control and vigilance systems, driver-only operations, and human performance considerations such as fatigue are among the areas of interest for the Australian Transport Safety Bureau’s ongoing investigation into a fatal collision between freight trains at Jumperkine in Western Australia.

At about 2am on 24 December 2019, Pacific National freight train 7MP5 collided with the rear of stationary grain train 2K66. The freight train’s lead locomotive was substantially damaged with a significant amount of grain entering the cabin, and the driver was fatally injured.

The ATSB’s preliminary report details the accident's sequence of events, established using a range of sources including the freight train’s data logger, and notes that when the grain train had come to a stop behind a red signal at Jumperkine, the freight train was 14.5 km behind and approaching Jumperkine.

Nearing Jumperkine the freight train passed a signal set at caution (yellow), then a Temporary Speed Restriction Ahead sign warning of a 30 km/h speed restriction in 2,500 metres. Shortly after the driver acknowledged an alert from the train’s vigilance* system, the train passed a Jumperkine signal set at stop while travelling at a speed of about 72 km/h.

The preliminary report then details that 60 metres after the stop signal, train 7MP5 passed the subsequent Temporary Speed Restriction Start sign, with the driver applying the service brake about three seconds later.

The train’s speed gradually reduced as it travelled around a sweeping left hand curve and onto a straight section of track. It is likely that the rear of the grain train came into view at about this point and an emergency brake application was made.

About 13 seconds after the emergency brake application freight train 7MP5 collided with the rear of the grain train 2K66.

Shortly before the collision, a network controller had attempted to contact the driver of 7MP5 after a Signal Passed at Danger or SPAD alarm was triggered, but there was no response. 

Investigators will examine the functionality of the relevant locomotive’s braking controls and vigilance system and undertake further analysis of available event data recorders and video recordings.

“ATSB preliminary reports detail basic factual information established in the investigation’s early evidence collection phase and do not contain findings, identify contributing factors or outline safety issues and actions, which will be detailed in an investigation’s final and any interim reports,” noted ATSB Director Transport Safety Dr Stuart Godley.

“In the coming months transport safety investigators will examine the functionality of the locomotive’s braking and vigilance control systems and undertake further analysis of event data recorders and video recordings,” Dr Godley said.

“Other areas of further investigation include risk controls associated with collisions and Signals Passed At Danger authority exceedances, a review of driver-only operations, human performance controls and well as factors affecting human performance such as fatigue, health and fitness.

“A final report will be released at the conclusion of the investigation, however, should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate safety action can be taken,” Dr Godley noted.

The preliminary report notes that Pacific National has proactively taken a number of safety actions since the accident, including adding a second crew member to trains operating between midnight and 6 am.

Read the preliminary report: Collision between freight trains 7MP5 and 2K66, at Jumperkine, Western Australia, on 24 December 2019

*A train’s vigilance system is a safety device that operates in case of incapacitation of the train driver for any reason. The system will react by directly initiating an emergency brake application if an acknowledgment input is not received within a specified time increment (in this case 50 seconds).

Weather a focus in ongoing investigation into fatal collision with terrain. ATSB preliminary report.

Meteorological conditions and pre-flight preparation are among the areas of focus in the ATSB’s ongoing investigation into the fatal collision with terrain of an amateur-built Wittman Tailwind light aircraft on 12 January.

The ATSB’s preliminary report details that the aircraft, registered VH-TWQ, had departed Evans Head, NSW, bound for Boonah, Queensland, with the pilot and one passenger on board, operating under visual flight rules (VFR).

The report notes the aircraft flew in a north-westerly direction towards Boonah before commencing a 180 degree turn overhead the township of Kyogle and diverting to the south to Casino. After about 45 minutes on the ground, the aircraft departed Casino to continue the flight to Boonah.

Approximately 15 minutes later, the aircraft was flying over the Tooloom National Park when recorded data shows it commenced a left turn before shortly afterwards colliding with terrain. The pilot and passenger were fatally injured and the aircraft was destroyed.

Due to the damage to the airframe, the aircraft’s attitude when it entered the tree canopy could not be determined.

Subsequent examination of the wreckage by ATSB transport safety investigators indicated that the aircraft collided with a number of trees before coming to rest on the rainforest floor. The aircraft’s structure was substantially disrupted, with the wreckage trail covering a length of about 120 metres.

“The ATSB’s ongoing investigation will include examination of the meteorological conditions and pre-flight preparation,” said ATSB Director Transport Safety Stuart Macleod. “Investigators will also examine the recovered wreckage, the aircraft’s performance characteristics and recorded flight data, and analyse the pilot’s qualifications and experience and the aircraft’s maintenance documentation and operational records.”

Mr Macleod stressed that this investigation is still in its early stages, and the ATSB will not publish its findings until the final investigation report is released.

“However, the ATSB does note that meteorological conditions and preflight planning are areas of focus for this investigation, and weather-related general aviation accidents remain one of the ATSB’s most significant causes for concern in aviation safety.”

To reinforce to visual flight rules pilots the dangers of flying into instrument meteorological conditions – IMC, and to highlight the actions they can take to avoid a weather-related accident, the ATSB has developed a safety promotion campaign titled ‘Don’t push it, DON'T GO – Know your limits before flight’.

“‘Don’t push it, DON'T GO’ highlights three key messages: the importance of thorough pre-flight planning and having alternate plans, that pressing on where there is the possibility of entering IMC carries a significant risk of spatial disorientation, and the value of using a ‘personal minimums’ checklist to help manage flight risks,” Mr Macleod said.

Flying into poor weather without the training and experience to do so can rapidly lead to spatial disorientation when the pilot cannot see the horizon.

“The brain receives conflicting or ambiguous information from the sensory systems, resulting in a state of confusion that can rapidly lead to incorrect control inputs and a resultant loss of control of the aircraft,” Mr Macleod noted.

“For pilots who fly under VFR, conducting thorough preflight planning and working to a personal minimums checklist aids sound decision-making both prior to take-off and during flight when faced with marginal weather or darkness.”

Findings from ATSB investigations into aircraft accidents where a VFR pilot flew into IMC are published in the ATSB’s recently updated Accidents involving pilots in Instrument Meteorological Conditions publication, re-released as part of the Don’t push it, DON’T GO campaign.

Read the preliminary report: VFR into IMC and loss of control involving Wittman Tailwind, VH-TWQ, Tooloom National Park, New South Wales, on 12 January 2020

With the devastating fires and floods, the ATSB acknowledges the contribution of many aviators.

With the devastating fires and floods affecting many areas across Australia in recent months, the Australian Transport Safety Bureau (ATSB) acknowledges the valuable contribution by many aviation operators who have safely supported communities in their times of need.

With unprecedented bushfires burning since September 2019, and more recently areas of severe flooding after a week-long down pour of welcoming rain, a high tempo of civil and military aviation activity has provided vital support during these natural disasters.

ATSB Chief Commissioner Greg Hood said pilots from a range of specialist sectors have helped assist impacted areas across the country to get back on their feet.

“I would like to acknowledge the continued safe work being done by so many people in the aviation industry – both civil and military – who have worked together during this unprecedented summer,” Chief Commissioner Hood said. “Flying in the adverse conditions that we’ve seen predominately along our east coast, whether it’s fighting the fires or supporting communities from the floods, is very challenging and with elevated levels of risk.

“As we all mourn the loss of three American aircrew who were tragically killed in late January when their C-130 Hercules collided with terrain at Peak View near Cooma, NSW, it is important for all of us in aviation to continue to safely serve our nation during this period of natural disasters.”

Australians are no strangers to bushfires and floods. The Australian aviation industry has been a part of the national fabric for many years, safely serving the people in rural and regional Australia, as well as those who live in the cities, safely in their times of need.

February 2020 marks the first anniversary of the Far North and North Queensland monsoonal floods, which caused devastation to cattle farmers across rural and regional Queensland.

“Aerial musterers play a vital role in the day to day operations of cattle stations across the top end of Australia,” Chief Commissioner Hood said. “During the floods last February in the northern parts of Queensland, a group of a dozen helicopter pilots from rural and regional Queensland safely supported farmers through this disaster for over a fortnight, even contributing to some of the costs from their own pockets. This is the true Australian spirit to help those in need during a time of crisis, and we are seeing this spirit reflected today.

“It is important to acknowledge the safe flying culture which is instilled in the Australian aviation industry. While the bushfire season is far from over, I would like to remind all pilots to continue to fly within the limits of their aircraft and themselves.”

ATSB releases C-130 large air tanker accident preliminary report.

The Australian Transport Safety Bureau has released the preliminary report from its ongoing investigation into the collision with terrain of a Lockheed C-130 large air tanker during aerial firefighting operations north-east of Cooma, NSW on 23 January 2020, in which three aircrew were fatally injured.

The preliminary report details basic factual information established in the investigation’s early evidence collection phase, including the accident’s sequence of events, wreckage and impact information, and weather details. The preliminary report also confirms that ATSB data recovery analysts were able to successfully download the C-130’s cockpit voice recorder (CVR).

“Although the recorder assembly was damaged in the accident, ATSB investigators were able to successfully recover all the data from the CVR’s crash protected memory module,” said ATSB Chief Commissioner Greg Hood.

“However, unfortunately the CVR had not recorded any audio from the accident flight. Instead, all recovered audio was from a previous flight when the aircraft was operating in the United States.”

The aircraft had been in Australia since November 2019, and why the CVR did not record the accident flight will be considered as part of the ongoing investigation.

“Audio from cockpit voice recorders often play an important role in aircraft accident investigations, however, our investigators do have a range of other evidence, including witness videos, at their disposal in building a comprehensive understanding of the accident sequence,” Chief Commissioner Hood said.

As the investigation continues, the ATSB will complete its teardown and inspection of the aircraft’s engines and propellers; review the aircraft’s maintenance history, and performance and handling characteristics; analyse witness reports; and develop a more comprehensive understanding of the accident impact sequence with the use of 3D drone mapping and video analysis of witness videos.

“The ATSB’s on-site examination of the wreckage, damage to the surrounding vegetation, and ground markings indicated that the aircraft initially impacted a tree in a left wing down attitude, before colliding with the ground,” Mr Hood said.

The investigation will also consider environmental influences; the crew’s qualifications, experience and medical information; the nature of aerial fire-fighting operations; and operating policies and procedures.

“ATSB preliminary reports do not contain findings, identify contributing factors or outline safety issues and actions, which will be detailed in an investigation’s final and any interim reports,” Mr Hood said.

“An investigation of this nature and complexity may take more than 18 months to complete.

“However, should any safety critical information be discovered at any time during the investigation, we will immediately notify operators and regulators, and make that publicly known.”

Mr Hood again extended his sympathies to those affected by this accident.

“On behalf of the ATSB, I convey our sympathies to the families and friends of the three aircrew who lost their lives in this accident in the service of others,” Mr Hood said.

“The ATSB would also like to acknowledge the support of the NSW Police Force, the NSW Rural Fire Service, NSW Fire and Rescue, the Australian Defence Force in facilitating safe access to an active fire ground and supporting our on-site investigation team. We also acknowledge and thank the warm-hearted support of the communities of Peak View and Cooma during the ATSB’s extensive on-site deployment.”

Read the preliminary report: Collision with terrain involving Lockheed EC130Q, N134CG, 50 km north-east of Cooma-Snowy Mountains Airport (near Peak View), New South Wales, on 23 January 2020

Ongoing investigation to examine engines, records and flight review requirements.

One of an Angel Aircraft Corporation Model 44 aircraft’s two engines was heard to ‘splutter’ soon after take-off from Mareeba Airport, Queensland, shortly before the aircraft collided with terrain, fatally injuring the two pilots on board, an ATSB investigation’s preliminary report into the 14 December 2019 accident notes.

The aircraft had been conducting a flight review — a regular assessment flight undertaken by all qualified pilots — with a Grade 1 flight instructor seated in the right seat and the owner pilot of the aircraft seated in the left seat.

The aircraft had commenced its initial take-off run just before 11.00am, with witnesses reporting that it sounded like one of the engines was hesitating or misfiring during the take-off roll, and with black sooty smoke seen trailing from the right engine.

Once airborne, the aircraft headed for the airfield’s training area. After eight minutes in the training area, the pilot seated on the left broadcast they were inbound to Mareeba and two minutes later broadcast that they were joining crosswind for runway 28. No further transmissions were heard from the aircraft.

An engine was then heard to splutter as the aircraft climbed to between 300 and 450 feet.

Witnesses reported seeing the aircraft touch down on the runway and take off again. An engine was then heard to splutter as the aircraft climbed to between 300 and 450 feet above ground level. The aircraft was next seen above a banana plantation beyond the end of the runway in a right descending turn, before it suddenly rolled right. Witnesses saw the right wing drop to near vertical and the aircraft collided with terrain in a cornfield.

Subsequent examination of the wreckage by ATSB transport safety investigators indicated the aircraft impacted terrain right wingtip first, followed by the nose, and left wingtip. The aircraft then pivoted about the left wing with the fuselage coming to a rest upright.

“The ATSB’s ongoing investigation will focus on further examination of the recovered engines and propellers, maintenance and operational records, aircraft and site survey data, pilot qualifications, experience and medical history, and regulatory requirements for flight reviews,” Dr Stuart Godley, ATSB Director Transport Safety, said.

Dr Godley noted that preliminary reports outline basic factual information established in the early phase of an investigation.

“Preliminary reports do not contain findings, identify contributing factors or outline safety issues and actions,” Dr Godley said. “These will be detailed in an investigation’s final report.”

Read the preliminary report: Loss of control and collision with terrain involving Angel Aircraft Corporation 44, VH-IAZ, near Mareeba Airport, Queensland, on 14 December 2019

ATSB preliminary report details loss of separation incident

The design of standard instrument approaches and departures, air traffic control and flight crew actions and procedures, and the coding of aircraft flight management system navigation databases are among a number of the factors the ATSB is focusing on as part of the on-going investigation into a loss of separation event near Sydney Airport.

That investigation’s preliminary report, released on 16 January, details that separation between two Qantas aircraft, an Airbus A330-300 and a Boeing 737-800, was reduced to about 0.43 nautical miles (796 metres) laterally and about 500 feet (152 metres) vertically during the incident, which occurred at around 6:30pm on 5 August 2019.

The A330 had been cleared by air traffic control to take-off from Sydney Airport’s runway 34 Right, at the same time that the 737 was on final approach to land on the same runway.

While the A330 was commencing its takeoff run, the air traffic controller with responsibility for managing runway 34 Right, an otherwise experienced controller who was a trainee under supervision for the Aerodrome Controller – East (ADC-E) position, assessed that if the 737 continued to land, there would be insufficient runway spacing between the two aircraft, and so instructed the 737 to conduct a go around.

The preliminary report details that the loss of separation occurred as both aircraft turned to the right.

The preliminary report details that the loss of separation occurred as both aircraft turned to the right, with the A330 turning to the right following a standard instrument departure (SID) from runway 34R (the MARUB 6 SID) and the 737 turning to the right following the missed approach procedure for a GLS (a global navigation satellite system landing system) approach for a landing on runway 34R.

The ADC-E controller, who reported that he had both aircraft in sight, attempted to increase their separation by instructing the 737 to turn further right. As both aircraft converged, the A330 flight crew received a traffic advisory (TA) alert from their aircraft’s airborne collision avoidance system (ACAS).

The A330 first officer, who was pilot flying, then saw the 737 in close proximity and, in response, reduced the aircraft’s angle of bank to reduce the turn towards the 737.

The captain of the A330 radioed to advise the ADC-E controller that their proximity to the 737 was “very close”. The controller then issued an instruction to the A330 flight crew to turn left.

The A330 climbed to 5,000 feet and continued to Melbourne without further incident. The 737 climbed to 3,000 feet and was issued radar vectors for a second approach to runway 34R. It landed without further incident a short time later.

“Preliminary reports outline basic factual information established in the early phase of an investigation. They do not contain findings, identify contributing factors or outline safety issues and actions, which will be detailed in an investigation’s final report,” explained ATSB Director Transport Safety Dr Stuart Godley.

“The ATSB’s on-going investigation into this occurrence will focus on a range of factors including the design and risk assessment of MARUB standard instrument departures and missed approaches from Sydney Airport’s runway 34 Right; air traffic control procedures, controller training and controller actions; flight crew actions and the operator’s procedures for the 737 and A330; coding of flight management system navigation databases; and further analysis of flight data recordings and ATC recordings.”

Read the preliminary report: Close proximity involving Boeing 737, VH-VZO and Airbus A330, VH-EBJ, at Sydney Airport, New South Wales, on 5 August 2019

The ATSB and the Australian Air Force Cadets’ ‘Pathways to an Aerospace Future’ program in 2020.

The Australian Transport Safety Bureau (ATSB) has signed an agreement of intent to support the Australian Air Force Cadets’ (AAFC) ‘Pathways to an Aerospace Future’ program in 2020.

The AAFC Pathways program, overseen by the AAFC Foundation on behalf of the AAFC, seeks to provide opportunities and experiences for cadets with a desire for a career or connection within the civil and military aerospace industries to help that become a reality.

Signing the agreement with AAFC Foundation Chair, Air Vice-Marshal (AVM) Kym Osley AM, CSC, following the Canberra based AAFC units’ annual parade at the Burgmann Anglican School Forde Campus on 30 November, ATSB Chief Commissioner Greg Hood said the Bureau intends to provide opportunities and access that supports four of the program’s six pillars.

“There are around 8,000 young people in the AAFC nationally because they have a keen interest in aerospace,” Chief Commissioner Hood said. “Many of them aspire to a career in the industry, and the ATSB is delighted to support the program and offer cadets opportunities focusing on leadership and personal development; technology and innovation; pathways to an aerospace career; and aerospace experiences.”

During a number of planned visits to the ATSB’s offices next year, cadets will learn about the role of the ATSB and how the agency works to improve safety for the travelling public, and will be given an overview of career opportunities at the ATSB and the entry requirements.

Both Greg Hood and AVM Osley are former Air Training Corps cadets (the predecessor organisation to the AAFC), and several ATSB staff and family members are also either current or former members of the AAFC.

Multiple brake applications failed to slow the train to avoid a collision with a rake of wagons.

Multiple brake applications by the driver of an empty bauxite train failed to slow the train to avoid a collision with a rake of wagons, an ATSB preliminary* report says.

On 22 September 2019, the empty bauxite train was travelling the 19.5 km track between Lorim Point and Andoom, near Weipa in Queensland. At the 17.5 km mark, the driver made a service brake application to the slow the train for the 25 km/h turnout as it neared Andoom, but the brake application did not slow the train. The driver then released the brake, applied the locomotive’s dynamic brake, and applied a service brake application for the second time.

Realising the train was not slowing, the driver made an emergency brake application, which was not effective. At 59 km/h, the driver applied the locomotive independent brake on the train. The independent brake only applies to the locomotive, but it did result in a slight decrease in the train’s speed.

The driver was aware that a train collision was imminent but was unable to prevent it.

The train passed through the turnout at 54 km/h. At the same time, a rake of wagons was being loaded at the automated loading point at Andoom, 635 m away. The driver was aware that a train collision was imminent but was unable to prevent it.

The train collided with the partially-loaded rake of wagons at 37 km/h. The locomotive of the moving train, and four empty wagons at the rear of the partially-loaded rake, derailed on impact.

The collision resulted in the modular driver operating cab separating from the main structure of the locomotive, coming to rest on the ground. The cab sustained substantial damage. The driver was initially trapped inside the cab but sustained only minor injuries.

The ATSB’s ongoing investigation will focus on the the crashworthiness of the modular operating cab design, factors associated with the function and use of the train brakes, and further analysis of the train’s event recorder and the operator’s policies, procedures and guidelines.

Read the preliminary report: Collision with rake of wagons and derailment of ore train R1006, Andoom (near Weipa), Queensland, on 22 September 2019

*Preliminary reports outline basic factual information established in the early phase of an investigation. They do not contain findings, identify contributing factors or outline safety issues and actions, which will be detailed in an investigation’s final report.

Pilots without a current instrument rating should be prepared to amend plans, and not to push on.

Following the release of two preliminary investigation reports into multiple fatality accidents where the aircraft involved were operating under visual flight rules (VFR), the Australian Transport Safety Bureau (ATSB) is again highlighting to pilots the actions they can take to avoid a weather or low-visibility related accident.

Today, the ATSB has released the preliminary* reports for the collision with water of Bell UH-1H ‘Huey’ helicopter VH-UVC, and the collision with terrain of Mooney M20J VH-DJU.

Five people were killed in the accident involving VH-UVC, which impacted the ocean after last light at a time of reported severe weather near Anna Bay, NSW, on 6 September 2019. Then on 20 September 2019, a father and son died when VH-DJU collided with heavily-wooded terrain in the Dorrigo National Park near Coffs Harbour, NSW, in forecast weather conditions of low broken cloud.

Both accidents are unrelated, but in both instances the flights were operating under visual flight rules, and neither pilot had qualifications to operate in instrument meteorological conditions (IMC) or at night, the preliminary reports establish. Further, both investigations will continue to look at the weather and environmental conditions at the time of the accidents, among a number of other factors.

“It is important to stress that both investigations are still in their early stages, and the ATSB will not publish its findings until the final investigation reports are released,” said ATSB Executive Director Transport Safety Nat Nagy.

“But the ATSB notes that weather and environmental conditions are a focus for both investigations, and weather-related general aviation accidents remain one of the ATSB’s most significant causes for concern in aviation safety.

Pilots without a current instrument rating should always be prepared to amend and delay plans to fly due to poor or deteriorating weather conditions, and not to push on.

“Weather and low visibility-related accidents often have fatal outcomes, which is all the more tragic because they are almost always avoidable.”

To remind VFR pilots of the dangers of flying into IMC, and to highlight the actions they can take to avoid a weather-related accident, the ATSB is currently running a safety promotion campaign titled ‘Don’t push it, DON'T GO – Know your limits before flight’.

“‘Don’t push it, DON'T GO’ highlights three key messages: the importance of thorough pre-flight planning and having alternate plans, that pressing on where there is the possibility of entering IMC carries a significant risk of spatial disorientation, and the value of using a ‘personal minimums’ checklist to help manage flight risks,” Mr Nagy said.

“Pilots without a current instrument rating should always be prepared to amend and delay plans to fly due to poor or deteriorating weather and environmental conditions, and not to push on,” he said.

“Have alternate plans in case of unexpected changes in weather, and make timely decisions to turn back, divert or hold in an area of good weather.

“Finally, setting expectations for your passengers beforehand can take the pressure off continuing with the flight if the conditions exceed your personal minimums.”

Source: ATSB

A total of 101 occurrences of VFR pilots inadvertently flying into IMC in Australian airspace were reported to the ATSB in the decade from 1 July 2009 to 30 June 2019. Of those occurrences, nine were accidents resulting in 21 deaths.

Findings from ATSB previous investigations into aircraft accidents where a VFR pilot flew into IMC makes for sobering reading. A selection of those findings are published in the ATSB’s recently updated Accidents involving pilots in Instrument Meteorological Conditions publication.

“The ATSB encourages VFR pilots to learn from the experiences of others, to help build a robust understanding of the risks of flying into IMC and just how rapidly such accidents can happen,” Mr Nagy said.

‘Don’t push it, DON'T GO’ follows on from a similar campaign the ATSB launched in 2018, titled ‘Don’t push it, LAND IT’, which was directed at helicopter pilots.

‘Don’t push it, LAND IT’ encouraged pilots to use their helicopter’s unique ability to make precautionary landings almost anywhere if faced with flying into IMC, fading day light or if something concerns them with their aircraft.

 “Know your limits before flight,” Mr Nagy said. “If you’re faced with deteriorating weather or if something just doesn’t feel right, don’t push it, make a precautionary landing. If you do decide to push on, it could be the beginning of an accident sequence.”

*Preliminary reports outline basic factual information established in the early phase of an investigation. They do not contain findings, identify contributing factors or outline safety issues and actions, which will be detailed in an investigation’s final report.

Read the preliminary report: Loss of control and collision with water involving Bell UH-1H, VH-UVC, 5 km south-west of Anna Bay, New South Wales, on 6 September 2019

Read the preliminary report; Controlled flight into terrain involving Mooney M20J, VH-DJU, 26 km west of Coffs Harbour Airport, New South Wales, on 20 September 2019

ATSB policy provides for identifying most organisations in its transport safety investigations. Most organisations directly involved in any aviation occurrence investigated by the ATSB are identified in the report and on the investigation web page.

The policy ensures the ATSB’s compliance with the International Civil Aviation Organization’s recommended practices. It also ensures that the ATSB has a consistent and transparent approach across all of its aviation, rail and marine safety investigations.

Operators and other organisations can be assured that it is not a function of the ATSB to apportion blame or determine liability. Including the name of the organisation does not imply any adverse inferences.

Which organisations are identified

For aviation, all operators and regulators are identified.

For marine, all ship owners, ship management companies and the regulator are identified.

For rail, rail transport operators (rail infrastructure managers and/or rolling stock operators) and regulators are identified.

Other large organisations that contributed substantively to the occurrence will also be mentioned. The exception to the above policy will be where the operator is an individual or an individual’s name is the company name. Consistent with the Transport Safety Investigation Act 2003, the ATSB does not name individuals in its final reports.

Are there any exceptions?

If an operator or organisation had a passive or third-party involvement in an occurrence, the ATSB will not name that operator in the investigation report or published information.

Operators and other organisations will not be named in investigation report titles.

This policy applies to safety occurrences investigated by the ATSB from 1 July 2017. Any incident or accident that occurred before 1 July 2017 was treated under the previous policy.

How will an organisation know if they’re named?

The ATSB provides advance copies of its investigation reports to all organisations involved in a transport safety occurrence. This ensures organisations are aware of, and have the opportunity to provide feedback on, the report’s contents before it is made public.