ATSB commends Jandakot air traffic controller for assisting student pilot 

The ATSB has commended the air traffic controller who was successfully able to guide a student pilot to a safe landing after the student’s instructor became incapacitated due to a medical episode.

ATSB Chief Commissioner Greg Hood presented the controller from Perth’s Jandakot Airport Tower with a Certificate of Commendation during a presentation at the Safeskies conference in Canberra on Thursday to acknowledge the controller’s calm professionalism in guiding the student to a safe landing.

“The controller worked with Airservices Australia’s highly capable team in Jandakot Tower to effectively manage the emergency situation," Chief Commissioner said.

“He calmly and competently provided instructions and advice to ensure the student pilot was able to make a safe landing at Jandakot. The controller, along with his colleagues in the tower, are commended for their professionalism and commitment to aviation safety.”

The student and instructor had departed Jandakot at about 5pm local time on 31 August 2019 for a training flight in the local training area, the ATSB’s Occurrence Brief report on the incident details. The student had a total of 2.4 hours flying experience but did not have experience flying the Cessna 152. It was the student pilot’s third flying lesson as his wife and three children watched from the ground.

While returning to the airport, the instructor experienced a medical episode due to an unknown and previously undiagnosed condition, and subsequently lost consciousness. The student took over control of the aircraft and contacted Jandakot Tower.

Under the guidance of the controller, the student was instructed to conduct a number of flyovers of the runway to gain situational awareness. The controller arranged for an instructor to assist the student from the tower, while ensuring all other aircraft remained clear of the airport while the student was able to practice approaches.

Once the student felt confident, the controller remained in contact to assist the student with landing the aircraft. Upon landing, emergency services vehicles attended the aircraft to assess the instructor.

“At all times, communication between ATC and the student was concise, informative and positive,” Chief Commissioner Hood said.

“During the time the flying instructor was incapacitated, both ATC and the student pilot communicated clearly, calmly and proactively, resulting in a safe landing.”

Commissioner Hood said the incident clearly highlights just how important effective communication is to aviation safety.

View an ABC News clip on YouTube featuring the radio transmissions between the Jandakot air traffic controller and student the student pilot here.(Opens in a new tab/window)

The ATSB has released its Annual Report, outlining its performance during 2018-19.

The Australian Transport Safety Bureau (ATSB) has released its Annual Report, outlining its performance during 2018-19.

ATSB Chief Commissioner Greg Hood said the Bureau continued to make a significant contribution to transport safety in Australia, thanks to the release of several substantial and high-profile investigation reports, which contained valuable safety learnings for the aviation, rail and marine transport modes.

“There was much attention on the agency in September 2018 with the publication of the final report from our investigation into a King Air aircraft’s collision with a building in a retail precinct at Melbourne’s Essendon Airport in 2017,” Chief Commissioner Hood said.

“The investigation drew upon the ATSB’s world-leading human factors capabilities, which resulted in safety messaging around the use of checklists as an essential tool for overcoming limitations with pilot memory and ensuring action items are completed in sequence without omission. This messaging highlights the ATSB’s approach to safety investigation, which is to ensure that all relevant lessons can be learnt to help stop accidents in the future.”

The ATSB’s significant contribution to safety internationally during the year was highlighted by the release of the final report from the investigation into a serious incident involving an ATR 72 turboprop airliner, which experienced an inadvertent pitch disconnect following an in-flight upset.

“The investigation into this complex event identified a number of safety factors, including some in relation to the continuing airworthiness of the aircraft, and aircraft certification standards,” Chief Commissioner Hood said.

“As a consequence, the ATSB issued Safety Recommendations to the European Aviation Safety Agency to review the current design standards in consideration of the effect that dual pilot control inputs may have on the safe operation of an aircraft.”

Another key highlight outlined in the annual report is the ATSB’s entering into a strategic partnership with RMIT University, which is a central element of the ATSB’s vision to create a centre of excellence for accident investigation and transport safety in the Asia-Pacific region.

"If the public trusts that investigators, regulators and operators are identifying and managing safety risks, then they will have confidence in the safety of the transport system"

“If the public trusts that investigators, regulators and operators are identifying and managing safety risks, then they will have confidence in the safety of the transport system,” Chief Commissioner Hood said.

“A significant achievement to realising this objective is the partnership between the ATSB and RMIT University. The ATSB is focused on ensuring its own people have the highest investigative capabilities and in educating others to achieve the same.”

Also during the year the ATSB’s operational efficiency was audited by the Australian National Audit Office (ANAO), which found the Bureau has established key elements of an overall framework to promote efficient investigation processes.

“The ANAO found that our efficiency had been declining, but that we have been focussing our attention improving investigation timeframes and moving to benchmark our performance against transport investigation entities in other countries” Chief Commissioner Hood said.

“The ANAO acknowledged a number of actions had already been taken by the ATSB to make improvements, including formalising aspects of our program-managed approach to investigations.”

The ATSB was notified of 17,454 incident and accident notifications across the aviation, rail and marine transport modes in 2018-19, and completed 44 complex investigations during the period.

Chief Commissioner Hood said the ATSB is well-positioned to continue making its important contribution to improving transport safety.

“The ATSB has been through significant organisational change over the last few years, all directed towards enhancing our productivity and building on our shared vision of being a world-leading transport safety investigation agency,” Chief Commissioner Hood said.

“The ATSB’s staff are dedicated, hard-working experts in their field, and their contribution to safety is highly valued and internationally recognised. I intend to ensure they are empowered and enabled to continue to make this contribution well into the future.”

Read the ATSB’s Annual Report 2018-19

New ATSB publication outlines proceedures following an on-airport aircraft accident

A new ATSB publication details the requirements of the national transport safety investigation agency following an on-airport aircraft accident or incident.

Launched today at Canberra International Airport’s celebrations to mark the start of Airport Safety Week, the Information and guidance for aerodrome operators publication outlines airport and aerodrome operators’ incident and accident reporting requirements to the ATSB, what to expect once an occurrence has been reported, and how to help preserve evidence for an ATSB investigation.

Emergency services and airport personnel have a critical role in responding to aircraft accidents and incidents, however this Airport Safety Week the ATSB is reminding them the importance of wreckage and ground scars being as little disturbed as possible.

“Airport operators having a thorough understanding of the role of the ATSB and the investigation process in the event of an aviation accident will help minimise disruption to airport operations,” ATSB Chief Commissioner Greg Hood said.

“This Airport Safety Week we are reminding airport operators of three key responsibilities in the event of an aviation accident: respond, report and preserve. Respond with their aerodrome emergency plan, report the accident to the ATSB, and along with emergency services preserve the accident site.”

Over the 10 years from 1 October 2009 to 1 October 2019, the ATSB’s National Aviation Occurrence Database shows approximately 25,500 incidents, serious incidents, and accidents have occurred within a one kilometre radius of Australia’s 31 towered civil and military airports. Of these, the ATSB has or is currently investigating 262 serious incidents and accidents.

Evidence preservation and collection is the first phase of any of our investigations,” Chief Commissioner Hood said.

“Critical evidence such as witness marks or small debris can be located some distance from the main accident site and spread over a very large area" 

"So it is imperative that all first responding agencies and airport operators proactively preserve all evidence at an accident site until our investigators arrive. This will greatly assist our investigators in their task of determining the factors that contributed to the occurrence.”

ATSB Transport Safety Investigators are based across the country and are on call 24 hours a day to deploy to an accident site as soon as practical, but the ATSB is not a first responder agency and it may take several hours before investigators arrive on scene.

“As we deploy, the ATSB will provide advice to first responders and airport operators to secure the accident site until we arrive,” Chief Commissioner Hood said.

“The ATSB is mindful of the effects an investigation can have on airport operations, however our priority will always be on conducting of a thorough and meticulous investigation to ensure that any safety issues are identified and addressed.

“Having a thorough understanding of our roles and requirements will greatly assist the ATSB accident investigation process, and help us to prevent similar accidents and incidents in the future.”

The Information and guidelines for aerodrome operators can be downloaded from the ATSB’s website, or printed copies can be ordered by emailing atsbinfo@atsb.gov.au

The ATSB welcomes the appointment of Mr Gary Prosser as a member of the ATSB Commission.

The Australian Transport Safety Bureau (ATSB) today welcomed the appointment of Mr Gary Prosser as a member of the ATSB Commission, effective from 1 October 2019.

Appointed by the Deputy Prime Minister and Minister for Infrastructure, Transport and Regional Development, the Hon Michael McCormack MP, Mr Prosser brings to the ATSB Commission over 35 years’ experience in the maritime industry, including a seagoing career serving on Australian ships in both international and domestic trades.

The ATSB’s Chief Commissioner, Mr Greg Hood, welcomed the expertise and experience Mr Prosser brings to the Commission.

“I have no doubt Mr Prosser will make a significant contribution to the ATSB's work of improving transport safety in Australia,” Chief Commissioner Hood said.

“I look forward to working with Mr Prosser as we position the ATSB to support and advance the national transport safety agenda.”

The Deputy Prime Minister also thanked the outgoing Commissioner, Mr Noel Hart, for his excellent contribution over many years.

“Mr Hart has provided invaluable maritime industry knowledge and experience to countless investigations. I wish Mr Hart all the best with his future endeavours and thank him for his exemplary ongoing contribution to Australia’s transport safety,” the Deputy Prime Minister said.

Chief Commissioner Hood also thanked Mr Hart for his commitment and passion for improving transport safety since he was first appointed as a Commissioner of the ATSB in July 2009.

“Noel has over 40 years’ experience in the shipping industry, with this knowledge greatly contributing to the investigations into the fatality on board the Skandi Pacific, off the Pilbara coast, Western Australia on 14 July 2015, the safety issue investigation into Queensland Coastal Pilotage in 2012, and the grounding of the Maersk Garonne, in Fremantle, Western Australia in February 2015,” Chief Commissioner Hood said.

Mr Hart also guided the establishment of the Bureau’s ‘SeaSafe 2019 Marine Safety Forum’, being held in conjunction with MIAL’s ‘Modern Martime Conference’ in Sydney next month.

“SeaSafe 2019 represents a unique opportunity for the maritime industry to address and confront safety issues, as the ATSB continues to work to improve transport safety in Australia,” Chief Commissioner Hood said.

“I wish Noel the very best for the future, and I thank him for his service.”

ATSB investigation analysis focused on risk to passengers.

The Australian Transport Safety Bureau stands behind its investigation that found a different and elevated risk for community service flights operated on behalf of Angel Flight Australia, compared to other private operations and commercial air transport.

The investigation into a collision with terrain of a SOCATA TB-10 Tobago, which had departed Mount Gambier to fly a young person and her mother to Adelaide for a medical appointment, looked beyond the accident flight to determine the broader systemic issues behind the provision of community service flights coordinated by Angel Flight.

“The Mount Gambier accident resulted in fatal injuries to the volunteer pilot and the two passengers, and was the second triple fatality accident involving an Angel Flight coordinated flight in seven years,” said ATSB Chief Commissioner Greg Hood.

“In both accidents, the pilots found themselves in instrument meteorological conditions without the necessary training, qualifications and experience to do so.”

Consequently, the ATSB’s investigation into the Mount Gambier accident sought to analyse the likelihood of a safety occurrence during an Angel Flight community service flight compared to other private operations. (Angel Flight Australia is a charity which matches volunteer private pilots flying private aircraft with regional and rural people needing transport for medical assistance.) Furthermore, the analysis was conducted to identify areas where Angel Flight organised flights are exposed to additional safety risks, regardless of attribution.

This analysis had not been undertaken before, as until recently, there was no way to differentiate community service flights from other private flights. Consequently, the ATSB undertook a data matching exercise to match Angel Flight records against the ATSB’s aviation occurrence database.

That analysis determined that between 2008 and 2017, 13,389 private flights carrying passengers were operated on behalf of Angel Flight, at a fatal accident rate of 1.5 fatal accidents per 10,000 flights, or more than seven times the rate (0.2 fatal accidents per 10,000 flights) for other private operations.

The ATSB focused on passenger carrying flights, as it was on these flights that Angel Flight passengers were exposed to risk (and was in line with the Minister for Infrastructure and Transport’s Statement of Expectations for the ATSB). Community service flights are also now defined by CASA as only those flights carrying passengers.

Further, the ATSB looked at flights, rather than flying hours, as the focus was on the likelihood a passenger would encounter a safety occurrence during a flight. Flights are commonly used when the data is available for operational safety analysis by the ATSB and others across the world, including the International Civil Aviation Organization.

It should be noted too that flying training flights, such as circuits, are not classed as private operations in the ATSB occurrence database.

Despite the focus on passenger carrying flights, with their occurrence rate more than four times higher than private operations, the ATSB’s investigation also showed that the non-passenger carrying flights repositioning to carry passengers for Angel Flight had an occurrence rate more than twice as high as other private operations. (The appendix to the ATSB investigation documents all safety occurrences for both passenger flights and the repositioning flights, and the results of both of these analyses.)

“The data analysis in the ATSB’s investigation was undertaken by experienced aviation safety data analysts and underwent extensive and robust peer review before publication,” Commissioner Hood said.

The ATSB’s data analysis also established that passenger carrying Angel Flight operations had a significantly higher rate of flight preparation and navigation occurrences when compared to other private operations.

These include visual flight rules pilots flying into instrument meteorological conditions, a known fatal accident pre-cursor, as was the case in the two Angel Flight fatal accidents.

The investigation established that Angel Flight coordinated flights were almost certainly exposed to different operational conditions, compared to other private flights, with the potential for pilots to feel perceived or self-imposed pressures to complete their flights.

The ATSB is continuing to monitor Angel Flight’s implementation of safety actions as advised by Angel Flight to reduce risk associated with the conduct of community service flights.

 “Angel Flight Australia’s statement issued on Tuesday afternoon in response to our investigation report raises a number of issues already addressed by the final report,” Commissioner Hood said.

“I would like to once again re-iterate that the ATSB is supportive of the community service flight sector, however, based upon the analysis conducted, it is essential that the controls for risk are strengthened to prevent further accidents,” Commissioner Hood said.

“I stand by our report and the thorough and diligent investigation team who produced it.”

The ATSB is Australia’s national transport safety investigator for the aviation, rail and marine modes of transport, and is completely independent of regulators, government agencies and service providers.

Read the report: Collision with terrain involving SOCATA TB-10 Tobago, VH-YTM, near Mount Gambier Airport, South Australia, on 28 June 2017

The ATSB is joining over 90 organisations promoting the message ‘Rail safety – it’s everyone’s responsibility’.

The Australian Transport Safety Bureau (ATSB) is joining over 90 organisations around Australia in promoting the message of Rail Safety Week 2019: ‘Rail safety – it’s everyone’s responsibility’, across 12–18 August.

Now in its 14^th year, Rail Safety Week is a nationwide initiative to remind the community to be aware when interacting with the rail network at all times – as road users and passengers – and to encourage safe behaviour.

The ATSB’s messages over Rail Safety Week will emphasise that potential dangers exist around a railway, including light rail.

The ATSB’s Chief Commissioner Greg Hood said Rail Safety Week was an important opportunity to bring the issue of rail safety to the attention of all Australians.

“As part of the ATSB’s efforts to promote Rail safety Week, we will be highlighting the safety messages of some of our investigations undertaken which tie directly to this year’s theme,” Mr. Hood said. “Rail safety is everyone’s responsibility, year-round. Please keep in mind this safety advice, not just for this week, but throughout the year.”

Please be patient and adhere to the signals and warnings signs at all level and pedestrian crossings.

The ATSB specifically reminds motorists, motorcyclists, cyclists, truck drivers, and pedestrians to take the utmost precautions when using level crossings.

“The ATSB has been called to investigate rail incidents and accidents that have resulted in serious injuries and the loss of life,” Mr Hood said. “Please be patient and adhere to the signals and warnings signs at all level and pedestrian crossings.”

The ATSB is the nation’s independent ‘no-blame’ rail safety investigator. Our investigations aim to determine what and why an accident happened, identify ongoing safety risks, and to influence safety actions to address those safety issues.

For more information, visit Rail Safety Week 2019’s website(Opens in a new tab/window)

The significant damage to the aircraft was indicative of a high speed impact.

Recovered wreckage from a two-seat Yakovlev Yak-52 aircraft’s fatal collision with water near South Stradbroke Island, Queensland on 5 June 2019 was consistent with a high-speed impact, an ATSB preliminary report says.

The Yak-52 had departed Southport airfield with a pilot and passenger on board at about 9:45 am for a 30-minute low-level scenic flight that was planned to include some aerobatic manoeuvres.

After concerns were raised when the aircraft did not return by the designated time, the Australian Maritime Safety Authority’s Joint Rescue Coordination Centre initiated search and rescue operations. Part of the aircraft’s propeller was located on the eastern side of South Stradbroke Island late that afternoon, while in the following days, the fatally injured pilot and passenger, plus additional wreckage, was recovered from the same area.

Recovered aircraft wreckage was consistent with a high-speed impact

The recovered wreckage, including a section of the left side of the fuselage and the tail section, a section of the right wing, seat cushions, and wooden propeller pieces, was indicative of a high-speed impact.

The ATSB’s ongoing investigation will focus on further examination of the recovered aircraft components, aircraft maintenance documentation, weather conditions, witness observations, and pilot qualifications, experience and medical history.

Read the preliminary report: Collision with water involving Yakovlev Aircraft Factories Yak 52, VH-PAE, near South Stradbroke Island, Queensland, on 5 June 2019

ATSB finds significant reduction in loss of separation occurrences in Defence-controlled terminal airspace.

Loss of separation incidents in Department of Defence controlled airspace around Darwin, Townsville and Williamtown/Newcastle airports have reduced significantly, the Australian Transport Safety Bureau (ATSB) has found.

As a consequence, the ATSB has now formally closed a Safety Recommendation it made to the Department of Defence in October 2013 following a research investigation into loss of separation occurrences, where there the minimum separation distances between aircraft was infringed, in Australian airspace between 2008 and 2012 (AR-2012-034).

“The ATSB issued a Safety Recommendation calling on the Department of Defence to review processes and risk controls in place to reduce both the disproportionate risk of loss of separation incidents in military terminal area airspace, particularly around Darwin and Williamtown, as well as the higher rate of air traffic controller actions contributing to loss of separation incidents,” said ATSB Director Transport Safety Dr Stuart Godley.

Darwin, Townsville and Williamtown/Newcastle airports are all joint-user airports with civilian and military traffic and where air traffic services are provided by the Department of Defence.

Follow-up ATSB analysis has found that all three locations had a lower rate of reported ATC-contributed loss of separation incidents.

At Darwin and Townsville, the ATSB notes that Defence has implemented Traffic Management Plans which have introduced a significant level of strategic separation principles for civil and military aircraft operating to and from both airports, enable predictability and certainty for civil aircraft operations as well as flexibility for military aircraft, in particular fighter type aircraft. Further, Defence continues to actively progress the recommendations and findings of an October 2015 joint CASA and Department of Defence aeronautical study of Williamtown airspace.

“Follow-up ATSB analysis has found that all three locations had a lower rate of reported ATC-contributed loss of separation incidents from 2013 to 2018 compared to the original research investigation period of 2008 to 2012,” said Dr Godley.

“While there is still an elevated risk of a loss of separation incident at Darwin due to pilot actions, the ATSB notes the unique mix of traffic at Darwin compared to comparable airports, and notes the Department of Defence’s commitment for an ongoing review of the traffic management plan at Darwin.

“Ongoing review may provide further opportunities to reduce the LOS incident rate at Darwin, in particular, those involving pilot errors.”

Dr Godley noted that a loss of separation occurrence does not necessarily mean there was a risk of collision between aircraft, or that the incident was a ‘near miss’, rather that separation standards were not maintained.

“Aircraft separation standards are set to ensure that the chance of a mid-air collision is very remote,” Dr Godley noted. “When they are infringed, there are fewer defences left to guard against a mid-air collision.”

Read the Safety Recommendation

1 July 2019 marks the 20th anniversary of the ATSB.

July 2019 marks the 20th anniversary of the formation of Australian Transport Safety Bureau (ATSB), Australia’s national transport safety investigator.

The ATSB was formed on 1 July 1999, with the amalgamation of the Bureau of Air Safety Investigation, the Marine Accident Investigation Unit, and non-regulatory elements of the Federal Office of Road Safety, and the establishment of a new rail safety investigation capability. The agency’s remit was to undertake independent “no blame” investigations into transport safety accidents and incidents to prevent future accidents, and to conduct transport safety research, data analysis and education.

“The ATSB is renowned internationally for its independence, technical capabilities and quality of its transport safety investigations across the aviation, rail and marine modes of transport,” said ATSB Chief Commissioner Greg Hood.

“On the occasion of the ATSB’s 20^th anniversary, I am immensely proud to be leading the organisation. I take pride in the ATSB’s world-class technical and research capabilities, but most importantly, I take great pride in the qualities and capabilities of our people.”

Today the ATSB employs a workforce of just over 100, based in the agency’s central office in Canberra plus offices in Adelaide, Brisbane, Melbourne, Perth and Sydney.

Almost two-thirds are Transport Safety Investigators, who come from a range of professional backgrounds, including pilots, licenced aircraft maintenance engineers, air traffic controllers, master mariners, train drivers and human factors specialists.

Other ATSB staff work in safety reporting, corporate functions and communications.

High profile investigations undertaken by current and former ATSB Transport Safety Investigators have included:

-          The grounding of the Border Force Cutter Roebuck Bay

-          The Qantas Flight 32 Airbus A380 uncontained engine failure

-          The derailment of freight train 9T92, which was loaded with sulphuric acid

“Today the ATSB takes a multi-disciplinary teams-based approach to investigations generating world-class investigation reports,” said Commissioner Hood.

“Those world class investigations have played no small part in ensuring Australia’s transport safety record is the envy of the world.”

Looking ahead the ATSB is preparing and positioning for the changing face of transport in Australia, especially with the rising use of remotely piloted aircraft and ever increasing automation.

“The ATSB is well prepared for the changing face of transport, and looks forward to contributing to further improvements in transport safety over the next 20 years.”

Investigation update into the Cessna 210 accident near Mount Isa, Queensland, on 26 May.

The ATSB has published an update on its investigation into the collision with terrain of Cessna 210 VH-SUX near Mount Isa, Queensland, on 26 May.

Evidence at the accident site indicated that the aircraft’s right wing had separated while in flight, resulting in a rapid loss of control and subsequent collision with terrain. The two pilots on board were fatally injured.

Subsequent technical examination confirmed the aircraft’s wing carry-through spar had fractured due to fatigue cracking, which reduced the spar’s structural integrity to the point where operational loads produced an overstress fracture.

“The ATSB has notified the Civil Aviation Safety Authority, the US National Transportation Safety Board, the aircraft manufacturer and operator of the initial finding of fatigue cracking with the wing spar carry-through structure,” ATSB Executive Director Nat Nagy said.

"The ATSB is working closely with those parties to ensure the continued safe operation of the the aircraft type."

The Cessna 210, which had been manufactured in 1976 and had accumulated over 12,000 flight hours, had been conducting a geological survey flight while flying at about 200 feet above ground level at the time of the accident.

The ATSB is working closely with those parties to ensure the continued safe operation of the the aircraft type.

The aircraft had been modified for geological survey work and had also been fitted with approved integral wing tip fuel tank and non-standard engine and propeller modifications.

“The ATSB notes that there is no evidence to indicate a connection between this accident and other recent investigations it has conducted involving this aircraft type,” Mr Nagy said.  

Read the investigation update: In-flight break-up involving Cessna T210M, VH-SUX, 25 km north east of Mount Isa Airport, Queensland, on 26 May 2019