The post-impact deployment of an aircraft’s rocket-deployed parachute recovery system is a reminder for emergency responders to approach aviation accident sites with caution.  

A Cirrus SR22 light aircraft collided with terrain during a night training flight at Orange Airport, New South Wales, on 15 May 2018. The pilot and flight instructor were seriously injured, and the aircraft destroyed. Footage from the airport’s closed-circuit television showed that the aircraft’s rocket-deployed parachute system discharged uncommanded around 9 minutes after the accident occurred. 

At the end of a second touch-and-go circuit, the aircraft struck the ground and collided with a fence, coming to a stop inverted. The ATSB found it was likely the pilot became spatially-disorientated after the initial pitch-up during the go-around manoeuvre, which obscured the horizon, resulting in a loss of control at low-level.

Copyright: Orange City Council has made this footage available under a Creative Commons licence.(Opens in a new tab/window)

The post-impact deployment of the aircraft’s parachute recovery system highlights an important safety message for emergency personnel and others who attend aviation accidents, to be aware of the potential dangers of an unactivated rocket-deployed parachute systems.

The mishandling or misidentification of these systems could be fatal.

The post-accident deployment of the Cirrus SR22's parachute recovery system highlights an important ATSB safety message for emergency personnel and others who attend aviation accidents to be aware of the potential danger of these systems.

Designed to be activated during a serious in-flight emergency, after a collision with terrain any deformation of the fuselage can put a rocket-deployed parachute recovery system’s activation cable under abnormally high tension, making it likely to deploy with any movement of the wreckage. 

In Australia, rocket-deployed parachute systems are installed in a range of light and sport aircraft including the Cirrus SR20 and SR22, the Pipistrel Virus and Sinus and the Sting TL-2000. They can also be retrofitted to the Cessna 150/152, 172 and 182 series.

Warnings about the presence of a rocket-deployed parachute system, while not consistent across aircraft types, can be found on either the external fuselage or the window adjacent to the parachute exit point.

Additional information for the identification of a rocket-deployed parachute recovery systems at aviation accidents sites is available in the ATSB’s publication Hazards at Aviation Accident Sites: Guidance for Police and Emergency Personnel.

Read the final report: Loss of control and collision with terrain involving Cirrus SR22, VH-PDC, Orange Airport, New South Wales, on 15 May 2018

Copyright: Orange City Council has made this footage available under a Creative Commons licence.(Opens in a new tab/window)

The ATSB is seeking your help in improving transport safety through completing our stakeholder survey. 

The ATSB is seeking your help in improving transport safety by providing feedback on the effectiveness of our stakeholder engagement and communications channels.

“By participating in our short 10-question survey(Opens in a new tab/window), you can help shape the ATSB’s transport safety messaging to industry, government and the travelling public,” said ATSB Communications Manager Paul Sadler.

“Communications and stakeholder engagement are the ATSB’s primary tools we use to influence improvements in transport safety, and so understanding our effectiveness in these areas is very important.”

The outcomes of this survey will help to guide the ATSB’s communications and education activities to help improve transport safety across the rail, marine and aviation modes.

Start our stakeholder survey(Opens in a new tab/window)

ATSB preliminary report into an Airbus Helicopters AS350’s collision with terrain near Woomera, SA.

The ATSB has released a preliminary report into an AS350 helicopter’s collision with terrain 60 km east of Woomera, SA, during powerline stringing operations on 20 March 2019.

The report outlines the established circumstances of the accident, in which the helicopter collided with a transmission pole during stringing operations for a new powerline to the Carrapateena mine site. The helicopter impacted terrain and the pilot, who was the sole occupant, received fatal injuries.

The ATSB deployed a team of five transport safety investigators to the accident site to examine the wreckage, interview witnesses, and recover a number of components for further examination.

The investigation is continuing and will include consideration of the pilot’s qualifications, experience and medical history, the maintenance documentation, and operational documentation.

A final report, which will include the ATSB’s findings and any recommended safety actions, is anticipated to be released in the first quarter of 2020.

However, should any safety issues be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate safety action can be taken.

Read the preliminary report: Collision with terrain involving AS350, VH-SZS, 60 km east of Woomera, South Australia, on 20 March 2019

The ATSB has renewed its partnership with the Defence Flight Safety Bureau.

The ATSB renewed its Memorandum of Understanding with the Defence Flight Safety Bureau (DFSB) during a brief signing ceremony in Canberra on 5 April.

The MoU provides a continuing framework for the ATSB and DSFB to cooperate in the investigation of aviation accidents and incidents, to provide mutual assistance, and to share expertise, training and resources.

Both organisations are committed to investigating accidents and analysing occurrence data under the ‘no blame’ philosophy, with the sole aim of preventing recurrences.

Under the MoU the two organisations can conduct joint investigations into aviation accidents and incidents, and assist with and participate in each others’ investigations.

Further, the MoU provides a mechanism for the Department of Defence to request ATSB assistance in areas of expertise such as failure analysis, cockpit voice recorder and flight data recorder analysis, analysis of head-up display and maintenance data, and digital animations; while the ATSB can request of DFSB assistance in areas such as aviation medicine, flight safety, systems engineering, aircraft avionics, and logistical support.

Pictured is ATSB Chief Commissioner Greg Hood and DFSB Director Group Captain Nigel Ward signing the MoU, witnessed by DFSB Deputy Director Safety Investigations, Wing Commander Sam Barnes.

Preliminary report released into runaway loaded ore train.

The ATSB has released its preliminary report into the runaway loaded ore train, M02712, 211 km south of Port Hedland, Western Australia, on 5 November 2018.

A loss of communication between the head end locomotive and the end of train monitor triggered an automated penalty brake application, stopping the train as it approached Garden South.

The driver alerted train control of the emergency, confirmed handbrake requirements, placed the reverser control to neutral, turned the generator field off and applied the independent brake before exiting the locomotive cab to begin manually applying handbrakes to the train’s 268 ore cars while awaiting assistance from a maintenance ground crew. During this time, an empty ore train, M02727, stopped on the adjacent track due to the blocking protections set up after train M02712 had stopped.

About 30 minutes later, the ground crew arrived and train control requested they start applying handbrakes from the rear of the train and proceed toward the driver who was working from the front.

Approximately 60 minutes after stopping, while still applying handbrakes, the driver of M02712 heard air venting from the brakes and noticed the train move forward slightly before commencing to roll away. Shortly after the driver alerted train control M02712 was a ‘runaway’. The Automatic Train Protection system triggered a number of penalty brake applications but these were ineffective.

The investigation is ongoing and the ATSB is constrained about what further information it can release publicly at this time.

Four minutes later, the driver of the empty ore train (M02727) advised train control the ground crew had mistakenly applied handbrakes to his train and not to M02712.

M02712 continued the runaway, reaching a speed of 162 km/h before slowing on a rise toward Woodstock.

Train control set a crossover to switch M02712 between adjacent tracks at Turner South and Turner North to derail the train. M02712 travelled through the Turner South crossover at 144 km/h and derailed. The lead locomotives travelling a further 1.6 km before coming to a stop.

The derailment destroyed two locomotives, 245 ore cars and 2 km of track infrastructure at Turner South.

The investigation is continuing and will look at a number of factors including the design of train braking systems used by the operator and procedures in the operator’s safety management system.

This preliminary report does not include any findings or recommendations – these will be provided in the final report, which we anticipate to be released in the fourth quarter of this year.

It is important to note that the investigation is ongoing and the ATSB is constrained about what further information can be released publicly at this time.

Read the preliminary report: Runaway and derailment of loaded ore train M02712, near the 211 km mark south of Port Hedland, Western Australia, on 5 November 2018

The latest figures on wildlife strikes shows the importance of reporting to the ATSB.

The latest breakdown of aviation wildlife strikes around Australia shows the importance of timely and thorough reporting to the ATSB, with 2017 showing the highest number on record.

Between 2008 and 2017, there were 16,626 confirmed birdstrikes reported to the ATSB. The number of reported birdstrikes has increased in recent years, with 2017 having the highest on record with 1,921.

Despite being a high frequency occurrence, birdstrikes rarely result in aircraft damage or injuries.

The number of birdstrikes involving a bird ingested into an engine in high-capacity air transport operations has risen in recent years with about one in ten birdstrikes for turbofan aircraft involving a bird ingested into an engine. Additionally, over the ten-year reporting period, there have been 11 occurrences involving one or more birds ingested into two engines of turbofan-powered aircraft.

The number of reported birdstrikes has increased in recent years…

Australian aviation wildlife strike statistics provide a reminder to aircraft and aerodrome operators to be aware of the hazards posed to aircraft by birds and non-flying animals. The growth of reporting to the ATSB over the last 10 years has helped to understand better the nature of birdstrikes, and what and where the major safety risks lie. The more detailed the information that is provided to the ATSB, the more accurate and useful reports like this one will be.

For the first time, Australian national wildlife strike data is available via an interactive web tool, allowing users to focus in, and get the information most important to their operations.

Read the research report, AR-2018-035: Australian aviation wildlife strike statistics 2008–2017

The ATSB has announced a strategic partnership with RMIT University that will see one of Australia’s leading tertiary institutions offer Transport Safety Investigator qualifications.

The Australian Transport Safety Bureau (ATSB) has announced a strategic partnership with RMIT University that will see one of Australia’s leading tertiary institutions offer Transport Safety Investigator qualifications.

Until now the ATSB has conducted its own nationally-accredited Diploma of Transport Safety Investigation training in-house.

But under a new partnership announced at the Australian International Airshow at Avalon Airport, Victoria on 27 February, RMIT will soon be offering a Graduate Certificate in Transport Safety Investigation, which encompasses the aviation, marine and rail transport modes.

Longer term, the Graduate Certificate qualification will create a pathway to further higher education programs leading to Graduate Diploma and Masters-level qualifications.

The partnership will provide industry in Australia and throughout the Asia-Pacific region with access to high quality, ATSB sponsored training in transport accident investigation, as well providing a framework to facilitate important transport safety related research through a credible university-based methodology,

RMIT Vice-Chancellor and President, Martin Bean CBE said the partnership with the ATSB was an historic one.

“Together we will work to improve transport safety throughout the Asia-Pacific region, across the aviation, maritime, and rail industries.”

“To achieve this, we will co-create and deliver tertiary level transport accident investigation qualifications to both ATSB staff and the broader transport safety sector”, Vice-Chancellor Bean said. 

“The relationship will also involve a range of collaborative research projects which will bring together RMIT’s deep expertise in delivering world-leading research with the ATSB’s considerable industry knowledge, intelligence and data access. Through this relationship we hope to facilitate an industry-wide capability improvement program throughout the Asia-Pacific region.”

ATSB Chief Commissioner, Mr Greg Hood said the new partnership was another key enabler that would support the Bureau to achieve its primary objective of improving transport safety through greater collaboration with a strong and highly credible research-led teaching and learning institution.

“This is a truly strategic partnership. Creating an offering where personnel can obtain and apply these qualifications within their respective industries will complement and enhance the ATSB’s primary objective of improving transport safety for all Australians,” Mr Hood said.

“RMIT has offered a long-term vision to support the partnership and proposes to create a centre of excellence in the field of accident investigation and transport safety in the Asia-Pacific region.”

“On behalf of the ATSB, I look forward to a long and productive partnership with RMIT and I look forward to seeing the Masters program mature over the next couple of years.”

Further information on the Graduate Certificate in Transport Safety Investigation can be found on the RMIT website.(Opens in a new tab/window)

Strategic Partnership Agreement signing on 27 February 2019

RMIT Associate Dean of Engineering, Aerospace Engineering and Aviation, Professor Pier Marzocca; ATSB Commissioner Chris Manning; RMIT Vice-Chancellor and President Martin Bean CBE; and ATSB Program Advisor Linda Spurr at the Strategic Partnership Agreement signing.

Driver maintenance of competency assessment process examined.

The ATSB has released its interim report into a signal passed at danger resulting in a near-miss between two suburban passenger trains at Bowen Hills, Queensland, on 10 January 2018.

The ATSB found train TP43 passed through signal ME45 while the signal displayed a stop indication. A signalling system generated an alarm to the network control officer at the Rail Management Centre, who issued an emergency stop command to the driver. The driver responded to the stop command and brought the train to a stop 125 m before the potential conflict point with another train, some 220 m past signal ME45.

During the course of the investigation, the ATSB found cause to examine Queensland Rail’s (QR) driver-competency management process or maintenance of competency (MOC) assessments.

After the incident the driver underwent a post-incident track observation that identified a number of safe driving deficiencies that were not in their previous MOC assessments.

Further examination found the driver’s detailed written responses in each MOC, were identical or near identical to those in the marking guide, with limited incorrect answers noted in the assessment.

Based on these findings, the ATSB analysed more than 50 systematically selected MOC assessment samples. Almost all showed a similar pattern.

ATSB is not stating that QR’s Citytrain drivers are not competent; rather, the application of the process for assessing competency has significant limitations

In response the ATSB released a safety issue to QR in September 2018 outlining its concern that the administration of their MOC assessment process provides limited assurance its Citytrain Rail Traffic Drivers meet relevant competency requirements.

In doing this, the ATSB is not stating that QR’s Citytrain drivers are not competent; rather, the application of the process for assessing competency has significant limitations.

The ATSB will continue to monitor QR’s response to the safety issue.

The investigation is continuing and will include an examination of among others policies, procedures and guidance related to the administration of train driver MOC assessments as well as processes used by QR to monitor the administration and effectiveness of the train driver MOC process.

The investigation is expected to be completed in the third quarter of 2019.

Read the interim report: Signal ME45 passed at danger involving suburban passenger train TP43 and near collision with another suburban passenger train, Bowen Hills, Queensland, on 10 January 2018

Aircrews are advised of increased chance of wake turbulence approaching Sydney Airport.

The ATSB advises flight crews of the increased likelihood of encountering wake turbulence when on approach to Sydney Airport.

An ATSB Bayesian analysis has concluded there is a disproportionate rate of pilot reported wake turbulence occurrences for aircraft arriving at Sydney Airport compared to other major Australian airports.

Sydney Airport is the only major Australian airport currently with parallel runways. The distance between these runways is such that they are treated as individual runways and do not require the application of the wake turbulence separation standard by air traffic control for aircraft operating to a single runway. None of the wake turbulence occurrences involved a breach of the separation standard.

More than half of the wake turbulence occurrences during arrival at Sydney Airport were associated with one or more of three factors

More than half of the wake turbulence occurrences during arrival at Sydney Airport were associated with one or more of three factors: high arrival densities across the parallel runway; wind blowing across the parallel runways from the longer to the shorter runway, especially when a heavy or super heavy aircraft was arriving on longer runway; and arrivals following an Airbus A380. The ATSB advises flight crews of the increased likelihood of encountering wake turbulence when on approach to Sydney Airport, particularly in peak periods, when operating on Runway 34 Right with the wind coming from the west or north-west, and/or when following an Airbus A380.

The ATSB has issued a Safety Recommendation to Airservices Australia to introduce measures to reduce the frequency of wake turbulence occurrence at the airport.

The ATSB agrees that measures being implemented by Airservices have the potential to reduce some of the wake turbulence events, however the ATSB encourages Airservices to consider conducting their own quantitative analyses to explore other options that could further reduce the risk of wake turbulence.

Read the full report AR-2017-011: Analysis of Wake Turbulence Occurrences at Sydney Airport 2012–2016

Results from ATSB survey of Australian commercial pilots on fatigue

The ATSB has released a research report outlining the results of a survey on experiences with fatigue by commercial pilots in Australia.

The research report, Fatigue experience and culture in Australian commercial air transport pilots (AR-2015-095), highlights the majority of pilot surveyed reported they were well rested at the end of their last duty.

Over half of the pilots reported having seven hours of sleep or more in the previous 24 hours, and over 60 per cent reported having more than 14 hours in the previous 48 hours at the end of their past duty.

ATSB Chief Commissioner, Greg Hood, said the report highlighted fatigue, and issues associated with fatigue, were not common in Australia, but some pilots do face operating in conditions conducive to fatigue.

“While small in number, some pilots did report operating in conditions consistent with thresholds that have been shown to be associated with impaired performance due to fatigue at the end of their last flight,” Mr Hood said. 

The report shows that 10 per cent of pilots reported obtaining less than five hours of sleep in the previous 24 hours, and 17 per cent reported they had less 12 hours in the previous 48 hours of their last fight.

The report also points to other areas for improvement, including organisational culture regarding the reporting of fatigue related issues.

“A third of surveyed pilots reported they had removed themselves from duty in the previous 12 months, however when they did this they reportedly felt it left a negative impression with management,” Mr Hood said.

“The responsibility to manage the risk of fatigue lies with both pilots and operators. Pilots need to use rest periods to get adequate sleep and remove themselves from duty if affected by fatigue and operators need to have polices in place to manage fatigue and create a work culture were pilots and crew can report fatigue in a supportive environment.”

The Civil Aviation Safety Authority (CASA) is currently consulting with industry on the introduction of the proposed CAO 48.1 Instrument 2019 – Modernising Australia’s Fatigue Rules(Opens in a new tab/window).

High-capacity regular public transport operators are required to transition to the new fatigue rules by 30 September 2019. All other operators will need to adopt the new fatigue requirements by 26 March 2020.

Advice on how pilots can manage their fatigue(Opens in a new tab/window) is also available on the CASA website.

Read the research report: Fatigue experience and culture in Australian commercial air transport pilots (AR-2015-095).