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).

The inaugural FlySafe 2019 Aviation Safety Forum will be held at the Avalon Airshow next month.

In a concerted effort to maintain Australia’s world-leading safety record, Australia’s three government aviation agencies are hosting the inaugural FlySafe 2019 Aviation Safety Forum at the Australian International Airshow next month.

The ATSB has further strengthend its close co-operation with the Defence Flight Safety Bureau.

The Australian Transport Safety Bureau (ATSB) has further strengthened its close co-operative arrangement with the Department of Defence, following the completion of a secondment of a Defence Flight Safety Bureau (DFSB) aviation accident investigator to the Bureau.

Squadron Leader Clare Fry, the second Defence aviation accident investigator to be seconded to the ATSB, brought her experience in safety investigation and human factors to the Bureau during her recent five-month secondment.

During her secondment, Squadron Leader Fry deployed to two accident sites involving general aviation aircraft, and was involved in two investigations focusing on high-capacity passenger aircraft. She also participated in a number of training courses, as well as human factors and professional development sessions.

Squadron Leader Fry said her time with the ATSB had been an excellent opportunity, and that she had gained valuable knowledge and experience.

“The ATSB are responsible for a much larger and broader demographic than DFSB, and therefore are exposed to a lot more,” Squadron Leader Fry said. “This has been a good opportunity for me to get some wider experience, and I’ll be taking that experience back to DFSB to strengthen our team.”

“The on-site experience with the ATSB, in particular, has given me some new insights into site safety management and risk assessments. I’m looking forward to the opportunity to incorporate ideas from the ATSB’s methodology to enhance Defence aviation safety investigation.”

ATSB Chief Commissioner Greg Hood said Squadron Leader Fry had been a valuable addition to the ATSB, and that her secondment resulted in both organisations benefiting.

“We are grateful to have had her as part of our organisation, and I’m glad that we continue to maintain and strengthen our already-strong relationship with our Defence counterparts at the DFSB,” Mr Hood said.

There is a close relationship between the two organisations, with a Memorandum of Understanding providing a framework for the ATSB and Defence to cooperate in the investigation of transport safety matters. Both organisations are committed to investigating accidents and analysing occurrence data, with the sole aim of preventing recurrence.

On Friday 17 November, the ATSB signed two new Memoranda of Understanding (MOU) with the Australian Federation of Air Pilots (AFAP) and the Australian and International Air Pilots Association (AIPA).

ATSB Chief Commissioner Greg Hood signed with AFAP President Captain Louise Pole and AIPA President First Officer Mark Sedgwick, respectively.

"The MOUs establish a framework that recognise our interests in working together to improve aviation safety," Mr Hood said. "The ATSB remains an independent body, but we recognise the value in ensuring we can tap into the highest levels of expertise to help us identify safety issues and get the message out there.”

Captain Pole acknowledged the initiative, saying "The ATSB plays an important leadership role as Australia’s national transport safety investigator. Our Safety and Technical Director Stuart Beveridge and Legal Counsel Joseph Wheeler along with myself and others at AFAP were delighted to have been involved in the drafting of this MoU. For 80 years the AFAP has been committed to improving aviation safety and we now look forward to the future opportunities that a more cooperative relationship will bring.”

First Officer Sedgwick for the AIPA said, “The AIPA has for some years had an MOU with the ATSB and we have strongly supported proposals to redevelop and expand an MOU between the ATSB and a wider range of industry participants. We remain committed to continuously improving aviation safety outcomes and our relationship with the ATSB is a vital component in achieving this. AIPA encourages all industry participants to work together to continually improve our already robust safety relationships. We congratulate Chief Commissioner Hood for taking this step and look forward to working with the ATSB."

The ATSB is signing a number of MOUs with industry associations to help with building relationships with organisations and people who share a common interest in improving transport safety.  Industry associations can be great advocates for safety action where it is needed.

The ATSB’s annual review of aviation safety occurrences is now with online interactive functionality.

The ATSB has released its annual statistical review of Australian aviation safety occurrences.

The report, which includes an online interactive function, brings together information over ten years – from 2008 to 2017 – to provide insights into current and possible future trends in aviation safety, and takes a detailed look at the accidents and serious incidents in 2017 for each type of aircraft operation.

The new interactive format enables the aviation industry, policy makers and researchers to create data sets specific for their needs, with detailed information on occurrences, operation type, location, injury, and aircraft type, able to be customised by the user.

This new functionality will display the information as charts, tables and on an occurrence map as well as provide links to relevant investigations on the ATSB website.

In 2017, nearly 200 aircraft were involved in accidents in Australia, with 203 involved in a serious incident (an incident with a high probability of an accident).

Across the different operation types:

• commercial operations experienced 14 fatalities from 21 accidents
• general aviation experienced 21 fatalities from 93 accidents
• recreational aviation had five fatalities from 53 accidents.

Sadly, 2017 saw an increase in the number of fatalities from aviation accidents, however – thankfully – there were no fatalities in either high or low-capacity regular public transport operations.

The interactive report underlines the importance of effective and timely reporting of all aviation safety occurrences to provide strong statistical bases for the study and analysis of aviation transport safety. The ATSB wishes to thank those in the aviation community, and the general public, who reported an aviation safety occurrences.

By providing a better way to compare aviation accident and occurrence data across a number different factors means everyone, not just the ATSB, can work to improve to aviation safety.

Read the report and Interact with the Australian Aviation Safety Occurrences, 2008-2017 report 

The report updates the known circumstances of the accident to date. The investigation is continuing.

The Australian Transport Safety Bureau (ATSB) have released an interim report into the collision with water involving DHC-2 Beaver floatplane, VH-NOO, which occurred at Jerusalem Bay, adjacent to the Hawkesbury River, NSW, on 31 December 2017.

The interim report updates the known circumstances of the accident to date, including the aircraft’s flight path prior to the accident, environmental conditions, post-accident aircraft examination, maintenance history and pilot experience.

ATSB Executive Director, Transport Safety, Mr Nat Nagy, said it is important to note the ongoing nature of the investigation.

“It is important to note that the ATSB’s investigation into this tragic accident is ongoing, so we are constrained on the information we can release publicly at this time,” Mr Nagy said. “However, the interim report, which we released today, does provide a factual update on the investigation so far. The report does not include any findings or recommendations – these will be provided in a final report, which we do anticipate to be released in the first half of next year.”

After taking-off from Cottage Point, the aircraft climbed and turned right into Cowan Creek heading towards the main Hawkesbury River into the prevailing wind on a standard departure path. However, while over Little Shark Rock Point, the aircraft made a right turn, reversing its direction. The aircraft levelled out before flying on a straight path directly towards Jerusalem Bay with a tailwind. Shortly after, the aircraft entered Jerusalem Bay at an altitude below the surrounding terrain height.

As the aircraft approached Pinta Bay the aircraft was witnessed to make a steep right turn. During the turn, the aircraft’s nose suddenly dropped prior to colliding with the water in a near vertical position.

The interim report outlines the post-accident aircraft examination and aircraft maintenance history with no evidence of any pre-existing issues found.

“With no on board data available from the aircraft itself, transport safety investigators have been able to use witness statements and images retrieved from one of the passenger’s cameras, to determine what happened in the lead up to this accident,” Mr Nagy said. “The ATSB’s investigation is continuing and will now look at a number of factors surrounding the pilot’s health and medical history.

“We have engaged an aviation medical specialist to assist with reviewing the pilot’s medical records as well as the autopsy results, which the ATSB has recently received over the past month. That review is now underway, and we expect the results to appear from that over the coming months.”

Read the interim report: Collision with water involving a de Havilland Canada DHC-2 Beaver aircraft, VH‑NOO, at Jerusalem Bay, Hawkesbury River, New South Wales, on 31 December 2017

Aviation human factors pioneer Dr Rob Lee AO was officially inducted into the Australian Aviation Hall of Fame (AAHOF) during a ceremony in Wollongong on 24 November at the Historical Aircraft Restoration Society’s (HARS) museum at the Illawarra Regional Airport.

The late Dr Lee, who passed away on 27 April 2018, is one of the first non-pilots to be inducted into the AAHOF.

Australian Transport Safety Bureau (ATSB) Chief Commissioner Greg Hood said Dr Lee was a visionary, who made an enormous contribution to the safety of aviation and other industries such as the nuclear industry, both here and overseas.

“He was a pioneer in ensuring that human factors became a key part of international aviation and other safety investigations,” Mr Hood said. “Rob was advised of his induction before he passed away and was greatly humbled and honoured. His passing was an enormous loss to the world, however he leaves a vast legacy in integrated safety systems and human factors.”

Attended by the Deputy Prime Minister, the honourable Michael McCormack MP (pictured above), Dr Lee’s partner, Sue, and brother Barry (pictured below), the induction ceremony remembered the professional triumphs of Dr Lee over his 40 years of service to Australian civil and military aviation.

In 1970, Dr Lee graduated from the Australian National University with First Class Honours in Psychology, winning the Australian Psychological Society Prize. In 1974, he completed his PhD in Psychology at the University of St Andrews, Scotland. His research focused on human performance in complex systems, with particular reference to aircraft operations.

In 1976, Dr Lee was appointed Senior Psychologist, Operational Command, Royal Australian Air Force (RAAF). He became the first RAAF psychologist to serve as a human factors specialist on RAAF aircraft accident investigation teams. In 1983, Dr Lee joined the Bureau of Air Safety Investigation (BASI) as the Bureau’s first human factors specialist. He established and developed the Bureau’s capability in human factors, systems safety and research. Dr Lee became Director of BASI in 1989.

During his directorship, he transformed the Bureau from a purely reactive investigative agency to an innovative multi-skilled organisation that concentrated equally on proactive accident prevention and safety enhancement. As Director of BASI, he increased practical cooperation in air safety investigation in the Asia Pacific region by negotiating memoranda of understanding with Indonesia, Singapore and Taiwan.

In 1999, Dr Lee was appointed Director of Human Factors, Systems Safety and Communications of the new multi-modal ATSB.

Dr Lee’s expertise was in high demand across multiple national and international investigations, including 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.

Retired Chief of Defence Force, Air Chief Marshal Mark Binskin AC, also paid tribute to Dr Lee’s legacy during the induction ceremony.

Chief Commissioner Hood said Dr Lee is remembered as being good humoured, having a positive manner and diplomacy.

“Dr Lee was a talented musician, as the lead guitarist of the band Mid-life Crisis,” Mr Hood said. “Every person in this room can settle more comfortably in their seats when flying because, indeed, the world is a safer place thanks to Dr Rob Lee.”

Dr Lee’s partner, Sue, and brother Barry pictured.

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