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.
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 14th 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.
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.
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.”
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 20th 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 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.”
Sighting from road vehicles can be severely restricted at passively protected crossings.
Sighting from road vehicles can be severely restricted at passively protected level crossings with an acute angle road-to-track interface, a new investigation highlights.
On 13 July 2016, a Warrnambool-bound passenger train collided with a semi-trailer at the Phalps Road level crossing at Larpent, near Colac, Victoria. The level crossing was passively controlled with stop signs.
When the truck initially stopped at the crossing, the train was more than 300 m away. The truck commenced moving towards the track when the train was between 220 and 260 m from the crossing. Unaware of the train approaching beyond his line of sight, the truck driver entered the level crossing.
The driver heard the train’s horn shortly before the locomotive struck the truck’s semi-trailer. After impact, the train’s locomotive and all passenger cars derailed. The locomotive driver, train conductor, 18 passengers and the truck driver were injured. There were no fatalities.
… sighting from road vehicles can be severely restricted at passively protected crossings with an acute angle road-to-track interface. It is important that available risk controls be deployed in these circumstances and road users take special care…
The investigation, conducted by Victoria's Chief Investigator, Transport Safety, on behalf of the ATSB, found the driver was unable to detect the approaching train on his left due to his restricted view from the level crossing’s acute road-to-rail angle and the composition of the truck’s passenger-side window.
The ATSB safety message from this investigation highlights that sighting from road vehicles can be severely restricted at passively protected crossings with an acute angle road-to-track interface. It is important that available risk controls be deployed in these circumstances and road users take special care.
The ability of a truck driver to see along a railway track to their left can be affected by in-cab obstructions. The Australian Design Standard for passively controlled level crossings accounts for this possibility by requiring a viewing angle of no more 110 degrees for a driver looking to their left from the straight-ahead direction. If this viewing angel is exceeded, passive level crossing controls should not be used.
The investigation found that for a vehicle stopped at the northern side of the Phalps Road level crossing, the viewing angle to achieve the required sighting distance was 116 degrees. The Phalps Road level crossing was subsequently upgraded to active protection controls in August 2016.
Since the accident, V/Line has taken action at 25 passenger line passively controlled level crossings with left-hand viewing angles that exceed the Australian Standard. Nine have been upgraded, one has had restricted access gates installed and 15 have had speed restrictions put in place. A further 24 crossings have also been nominated for upgrade.
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.
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.
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.
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.
