The Australian Transport Safety Bureau (ATSB) has released its Annual Report, outlining its performance during 2017-18.

ATSB Chief Commissioner Greg Hood said the report describes the Bureau’s continual path of transformation.

“In my second year as Chief Commissioner, the team and I have continued to position the ATSB as a multi-modal, teams-based, world-class transport safety investigation agency,” Mr Hood said.

“We also prioritised the completion of a number of complex investigations, which delivered safety outcomes and also freed up key resources for new investigation priorities.”

With the Australian Government’s allocation of additional funding to address resourcing challenges encountered in previous years, Mr Hood said this funding has put the ATSB on a positive path of transformation.

“During the period, we recruited 17 new Transport Safety Investigators, who are already making an active contribution to transport safety,” Mr Hood said.

“The investment made over the period will see continued improvement towards the ATSB being able to meet its deliverable targets.

“We are investing significantly in the development of our investigators to position them to be able to disseminate safety findings to industry and the public as quickly as possible.”

With 16,522 incident and accident notifications received across the aviation, rail and marine transport modes in 2017-18, the Annual Report highlights some of the 40 complex investigations completed during the period, including the collision with terrain involving an Airbus Helicopters EC 135 T1 at Cooranbong, New South Wales in 2015.

“The safety message from this investigation was avoiding deteriorating weather conditions requires thorough pre-flight planning,” said Mr. Hood.

“Flying on into instrument meteorological conditions without a current instrument rating carries a significant risk of encountering reduced visual cues leading to disorientation.”

This investigation led to the launch ‘Don’t Push It, Land It’ – a safety initiative for the helicopter industry, developed in conjunction with the Australian Helicopter Industry Association (AHIA) and the Civil Aviation Safety Authority (CASA).

The ATSB also commenced some significant investigations in 2017-18, including the collision with water involving a DHC-2 Beaver floatplane, which occurred on the Hawkesbury River, north of Sydney, on New Year’s Eve.

ATSB Chief Commissioner Greg Hood said the report describes the Bureau’s continual path of transformation.

Over the next few years, the ATSB expects to see significant changes in the transport sector, with the increased use of automation or remotely piloted operations.

“Whilst we have restructured, we have maintained a strong focus on the quality of our evidence-based investigations. The focus in 2018–19 will be to make progress in addressing some of our key performance indicators around the timeliness for completion of reports,” Mr Hood said.

“I am confident that we can make good progress, particularly following our recent investigator recruitment exercise. The year will be a positive one, with our team committed to making our aviation, rail and marine modes of transport even safer.”

Read the ATSB’s Annual Report 2017-18

Collisions at sea can endanger the lives of those on board and can cause significant structural damage to the vessels involved.

Speaking in the Australian Maritime Safety Authority’s (AMSA) Working Boats magazine, ATSB Executive Director Transport Safety, Mr Nat Nagy said that over the past 28 years the ATSB had investigated 38 collisions between large ships and small vessels.

“A proper and effective lookout and early avoiding action could have reduced the risk of any one of these collisions happening,” Mr Nagy said.

A proper and effective lookout by all available as defined by the international collision regulations (COLREGs) includes the use of radar, automatic identification systems, electronic chart displays, information systems, radio broadcasts, and ship-to-ship calls as well as keeping a look out by sight and hearing.

In addition to the material in the Working Boats magazine Mr Nagy went on to say that, the COLREGs apply to all vessels, in all waters.

“It’s not just about having the right electronic equipment. Crews need to be able to engage actively with the equipment and their surroundings,” Mr Nagy said.

“Those keeping watch need to take frequent and accurate compass bearings of any approaching vessel and ensure regular plotting and systematic analysis of the information they have to hand.”

Small ships can improve their detectability with AIS transceivers and radar reflectors.

“This equipment also helps smaller vessels detect other vessels and provides important dynamic and static ship information to help detect approaching vessels and avoid a collision,” Mr Nagy said.

For more information on this and other marine safety issues read the September edition of AMSA’s Working Boat(Opens in a new tab/window) magazine 

The Australian Transport Safety Bureau (ATSB) has joined the aviation industry in supporting Airport Safety Week 2018.

Airport Safety Week – a collaboration between the Australian Airports Association (AAA) and the NZ Airports Association (NZ Airports) – is an annual forum for learning and innovative thinking in the field of aviation safety.

ATSB Chief Commissioner, Greg Hood, who attended this year’s launch at Canberra Airport on Monday morning, said Airport Safety Week is an important opportunity for all airport users to share their insights and experiences in maintaining a safe environment.

“Airports are, naturally, a critical element of the aviation safety system,” Mr Hood said.

“They are a confluence of activity and information, and the experience, knowledge, and professionalism that we see at Australian and New Zealand airports is one of the reasons why aviation safety in this region is of such a high calibre.”

This year’s theme, ‘Walk in my shoes’, reminds the aviation industry of the many different organisations and individuals who contribute to airport safety.

The Airport Safety Week affords all airport operators, airlines, pilots, emergency services and aviation safety agencies the opportunity to work together to improve the understanding of each other’s roles, and to build even more collaborative relationships.

The ATSB provides research materials and educational resources about transport safety to airport operators and users. In the event of an emergency at or near an airport, the ATSB and the Defence Flight Safety Bureau, have developed a booklet called ‘Hazards at an accident site’. The pocket-sized booklet is an easy-to-understand mainstay of do’s and don’ts for first responders attending a range of aviation accidents.

“The booklet explains the dangers that can exist, and provides guidance on how to keep safe while responding to an aviation accident,” Mr Hood said.

“I encourage airport operators to have it as part of their safety library. Contact our Communications team for a copy, or download it from the ATSB’s website.”

Coinciding with Airport Safety Week, on Friday Chief Commissioner Hood will be presenting at the AAA’s 2018 Emergency Management Forum in Canberra.

A new exhibit installed at the ATSB’s Canberra offices explores the past and present of transport safety investigation in Australia.

On Tuesday, 2 October 2018, the Director of the Australian War Memorial Dr Brendan Nelson AO, and the ATSB Chief Commissioner Greg Hood, formally unveiled the new display in the foyer of the ATSB’s Canberra headquarters.

The exhibition is designed to not only capture the agency’s history through showcasing past investigations, but to also be contemporary in that it displays a range of new developments and techniques in how transport safety investigations are conducted.

On prominent display is the pursuits of Dr David Warren AO, who introduced the use of recorder technology to assist with aviation safety investigations. Several items trace the evolution of the ‘Black Box’ flight recorder, through to the flight data and cockpit voice recording devices in use today.

The exhibition also looks at new developments and techniques in transport safety investigation. On display are items exploring the ATSB’s growing use of forensic information-recovery from smartphones, tablets, digital cameras, and GPS navigation devices.

ATSB Chief Commissioner Greg Hood said the preservation and display of transport safety investigation history is important for the ATSB.

“This exhibit showcases the history of transport safety investigation in Australia,” said Mr Hood.

“Australia has been at the forefront of transport safety for many years. It is important that we preserve and display our history, and this exhibition shows just some the work of the ATSB and our predecessors have undertaken to improve safety for the travelling public.”

The display is located in the foyer of the ATSB’s headquarters at 62 Northbourne Avenue, Canberra, and is open to the public during regular business hours.

The Australian Transport Safety Bureau (ATSB) recently met with its New Zealand counterpart the Transport Accident Investigation Commission (TAIC), to discuss transport safety matters in the region.

The visit to TAIC’s headquarters in Wellington last week afforded ATSB Chief Commissioner Greg Hood, TAIC Chief Commissioner Jane Meares, and Commissioners from both agencies, the opportunity to share information relating to transport safety trends, and discuss several high-profile investigations.

Chief Commissioner Hood said the visit was a valuable opportunity to learn from each other’s investigation experiences.

“The ATSB and the TAIC have the same mission of improving transport safety for the benefit of the travelling public,” Mr Hood said.

“While we go about this in our own ways, it is valuable to understand how a different approach can bring different insights and strengths to an investigation. It was also helpful to discuss the challenges we both encounter during investigations, and the ways in which we overcome them.”

The meeting allowed the Chief Commissioners to sign a revised Memorandum of Understanding (MOU), re-affirming that in the event of a major accident, each agency stands ready to offer support and assistance.

“The strong relationship between the ATSB and the TAIC makes for safer transport within our region, and we are committed to working together to make it even safer,” Mr Hood said.

“Transport safety investigation is a unique endeavour, and we are anticipating that a closer relationship will allow us to share safety outcomes more effectively.”

The ATSB and the TAIC are continuing to work closely on a range of opportunities for the mutual development of their investigation capabilities.

Photos - Colin McDiarmid

The ATSB has issued a safety advisory notice to all operators flying to Brisbane Airport.

The ATSB has issued a safety advisory notice to all operators flying to Brisbane Airport to consider the use of pitot probe covers there and to have rigorous processes in place to confirm the covers are removed before flight.

The release of the safety advisory notice comes after the publication of the ATSB’s preliminary report into an airspeed indication failure on take-off involving Airbus A330, 9M-MTK, Brisbane Airport, Queensland on 18 July 2018.

The ATSB found that local engineering support crew placed covers on the pitot probes soon after the previous landing. Inspections during the aircraft’s turnaround did not identify their fitment and they remained on the aircraft for its departure. This resulted in unusable airspeed information being displayed to the flight crew. The flight crew continued the take-off and carried out several checklists before returning to Brisbane Airport.

ATSB Chief Commissioner Greg Hood said unobstructed pitot probes are critical to flight safety.

“This is a serious incident. The CCTV footage reveals that the three pitot covers were in place on the aircraft as it pushed back from the terminal and as it accelerated down the runway,” Mr Hood said.

“This limited the amount of information – the critical information – that is available to flight crew during the take-off and during the short flight, up to 10,000 feet, and then the return to Brisbane Airport where the aircraft landed safely.”

"The CCTV footage reveals that the three pitot covers were in place on the aircraft as it pushed back from the terminal and as it accelerated down the runway."

Several high-capacity aircraft have departed from Brisbane with one of the pitot probes blocked by insect nests in recent years, including two that resulted in rejected take-offs investigated by the ATSB.

The airport has had a wasp eradication program since 2006 and the Civil Aviation Safety Authority and Airservices Australia have issued advice about the risk they pose, with some operators now using pitot probe covers for short turnarounds.

“Today we are issuing a safety advisory notice to all operators to take particular care and review their procedures for the fitment of pitot covers on landing at Brisbane Airport and ensure their processes are robust for the removal of these covers prior to flight,” Mr Hood said.

“Our investigation is continuing. We will be focusing specifically on the procedures for flight crew and ground crew in relation to the pre-flight checks for the aircraft, and also the cockpit warning systems received by the flight crew as they accelerated down Runway 01.”

Read the preliminary report: Airspeed indication failure on take-off involving Airbus A330, 9M-MTK, Brisbane Airport, Queensland, on 18 July 2018

Read the Safety Advisory Notice: Managing the use of pitot probe covers at Brisbane Airport

Through collaboration with the Office of the National Rail Safety Regulator (ONRSR), the ATSB is gaining access to a detailed data feed of rail safety occurrences, as well as many years’ worth of historical records.

Rail safety data in Australia comes from many different sources and covers a large spectrum of operations. This includes the interstate rail network, suburban and intrastate rail networks, and private rail networks.

Originally, the ATSB had a limited focus on accidents and incidents that occurred on the interstate rail network. More recently, as part of the national rail safety reforms, the ATSB’s rail safety investigation role has been expanded to include all operations within every Australian state and territory.

ATSB Executive Director of Transport Safety, Mr Nat Nagy, said the access to the new data represented an important step forward.

“Previously, there were significant limitations – some information was limited to the interstate rail network, and only consisted of certain details,” Mr Nagy said. “The new data covers everything, including suburban rail. It’s going to provide invaluable context to our rail safety investigations.”

The ATSB previously had access to limited occurrence information held by regulators in each state and territory. The limitations made it difficult for the ATSB to conduct significant analysis of rail safety events, preventing any effective analysis of safety trends and statistics.

The ATSB now receives a daily feed each evening from ONRSR containing a complete update of all occurrences reported by the rail industry, Australia wide. The ATSB can now combine this information with its own data holdings on safety investigations to form a rich data set.

In addition to the new flow of current information, there is a transfer of historic occurrence records dating back to 20 January 2013. Over 208,000 records are migrating over to the ATSB databases. Some of the occurrences recorded are highly significant, others are routine, but combined they form a detailed picture of rail safety in Australia.

Mr Nagy anticipates this new access will be of tremendous value in advancing rail safety in Australia. “This is going to enable the ATSB to conduct much more effective rail safety research and analysis,” Mr Nagy said. “Our investigators will be able to drill down into the details. We will be looking to identify trends and problems before they become significant.”

The Australian Transport Safety Bureau’s (ATSB) Chief Commissioner, Greg Hood, is using this year’s Rail Safety Week to remind drivers of the hazards around level crossings.

The ATSB’s investigations involving collisions between vehicles and trains on level crossings have shown that death and injuries on the nation’s rail networks are avoidable if people obey the rules and remain aware and alert at all times.

“We see vehicles, and pedestrians too, continuing taking risks when it comes to using level crossings,” Mr Hood said. “Impatience and lack of awareness are some of the key contributing factors to these kind of accidents. Drivers need to be fully aware of their surroundings at all times and think about their actions when approaching level crossings.”

Rail Safety Week, which runs until 19 August, is not just about drivers taking greater responsibility, with this year’s safety focus also involving rail workers. The ATSB has investigated several accidents involving maintenance repair work on track.

Mr Hood says conducting work on or near track can be dangerous if safe working rules and procedures have not been correctly implemented to protect the worksite.

“Rail workers have a right to come home every night after work, but they need to be absolutely vigilant when working on or near tracks to ensure they coming home safely every night,” Mr Hood said. “This means effective communications amongst all workers at all times. Trains can’t stop quickly and any breakdown in the communication or management of a worksite can leave workers extremely vulnerable.”

Mr Hood said the ATSB was united with the rail industry, regulators, government, road safety and police partners in promoting safety in and around the rail network.

“Rail safety is ultimately everyone’s responsibility, whether you are a member of the public, rail worker or rail operator,” Mr Hood said. “Be sensible, pay attention and be alert.”

The ATSB welcomes the announcement of the induction of aviation safety visionary Dr Rob Lee AO into the Australian Aviation Hall of Fame (AAHOF).

From 1989 until 1999, Dr Lee led the ATSB’s predecessor – the Bureau of Air Safety Investigation (BASI) – transforming it from a purely reactive investigative agency to an innovative multi-skilled organisation that concentrated equally on proactive accident prevention and safety enhancement.

Dr Lee’s expertise was in high demand across multiple national and international investigations, including into the Gulf Air A320 accident at Bahrain in August 2000, the Singapore Airlines B747 accident at Taipei in October 2000, and the mid-air collision between a B757 and a TU154M over Ueberlingen, Germany, in 2002.

He served as a member of the International Society of Air Safety Investigators, the European Association for Aviation Psychology (EAAP), and the Australasian Society of Aerospace Medicine. He was also Vice-President of the Australian Aviation Psychology Association.

Dr Lee was recognised with many distinguished honours nationally and internationally during his career. In the 2012 Queen’s Birthday Honours, Dr Lee was made an Officer in the General Division of the Order of Australia (AO): “For distinguished service to the aviation industry, to the development of air safety and accident investigation standards, and to national and international professional associations”.

Chief Commissioner Greg Hood said the announcement that Dr Lee was being honoured by being inducted into AAHOF was welcome news and well deserved. 

“Dr Lee was a visionary, who made an enormous contribution to the safety of the aviation industry both here and overseas,” he said. “He was a pioneer in ensuring that human factors became a key part of international aviation safety investigations. Rob was advised of his induction before he passed away on 27 April 2018 and was greatly honoured. His passing was an enormous loss to the world; however he leaves an enormous legacy in integrated safety systems and human factors.”

For further information on the AAHOF and its inductees, visit aahof.com.au(Opens in a new tab/window)

The ATSB has acquired a new scanning electron microscope (SEM) – a JEOL JSM-IT500 – to replace a 14-year-old instrument that has been used extensively to help improve transport safety by forensically examining and analysing components from transport safety occurrences.

ATSB Chief Commissioner Greg Hood said the purchase of the new SEM was an important investment in maintaining and improving the Bureau’s capabilities.

“Electron microscopy has been a key part of the ATSB investigation capabilities for many years,” Mr Hood said. “Our investigators use electron microscopy for forensic examination and failure analysis of components. By examining material at tremendous magnification, our investigators can identify minute details that can provide invaluable insight into the factors contributing to these occurrences.”

The SEM, manufactured by JEOL in Japan, took two days to install and calibrate at the ATSB’s Canberra headquarters, and is the first model of its type in Australia.

“Our Transport Safety Investigators are very excited about the microscope’s potential,” Mr Hood said. “They have already found it is faster, easier to use than our previous equipment and the quality of the images is better. In addition to its capabilities, the SEM is going to help make transport safer.”