Today (Friday 7 December) is International Civil Aviation Day, established by the United Nation’s International Civil Aviation Organisation (ICAO) in 1994 to raise awareness of the importance of international social and economic development in civil aviation.

This year, the day aims to highlight how ICAO’s ‘No Country Left Behind’ (NCLB) initiative encourages member states to assist developing countries so they too can enjoy the benefits of safe and reliable air transportation. NCLB is a broad strategic approach to encourage and assist all ICAO States to meet ICAO’s Standards and Recommended Practices (SARPs).

The Australian Transport Safety Bureau’s Chief Commissioner, Greg Hood, said the Bureau participates in the spirit of the initiative though its involvement in ICAO’s Asia Pacific Accident Investigation Group.

“The day also focuses attention on how ICAO and its member States, like Australia, can work together to encourage and provide assistance to developing countries and their air transport networks,” Mr Hood said. “Through participation in this group, the ATSB works with nations in the region to assist with the establishment and development of their own capability for the independent investigation of aviation accidents and incidents.”

In October, the ATSB and the Indonesian National Transportation Safety Committee (NTSC) conducted a two-day investigation analysis workshop in Bangkok, Thailand, as part of the ICAO Asia Pacific Accident Investigation Group program.

“Participants from 15 nations including Bangladesh, Brunei Darussalam, Cambodia, Macau, India, Indonesia, Japan, Malaysia, Mongolia, Myanmar, New Zealand, Philippines, Korea, Singapore, and Thailand attended the workshop,” Mr Hood said. “Workshop participants received specialist instruction in investigation analysis methodology and completed a range of group exercises to apply the techniques they had learned.

“The success of the investigation analysis workshop clearly demonstrates how ICAO States in the Asia Pacific can work together to improve aviation safety in the region, for the benefit of all.”

More information on International Civil Aviation Day is available on ICAO’s website - www.icao.int(Opens in a new tab/window)

A tragic accident carries important safety messages for aerial application pilots.

The ATSB’s investigation into the fatal accident of an Air Tractor AT-502 revealed several factors that contributed to the tragedy, and the measures that aerial application pilots and operators need to be taking.

The accident occurred on 5 November 2016 at an airstrip at Cryon, NSW. The aircraft was conducting aerial application operations. After commencing the take-off, the aircraft failed to gain any significant altitude, and clipped the top of a fence about 1,300 m beyond the start of the runway. After climbing about 20 feet above the ground, the aircraft descended, and collided with trees and the ground before coming to rest inverted. The pilot was fatally injured, and the aircraft was destroyed by impact forces and a fuel-fed fire.

The ATSB investigation found that the flaps were either never extended or were retracted at some point during the take-off. The reason for the retraction could not be determined, but it significantly degraded the take-off and climb performance. This effect was compounded by the estimated weight of the aircraft, the local temperature and the wind conditions.

The aircraft reached a height above the ground where the reduced benefit of ground effect further degraded the aircraft’s performance. The low height and airspeed precluded the pilot from turning the aircraft towards a clear area, and so the aircraft descended into the trees.

... the aircraft manufacturer is updating the maintenance section of the aircraft owner’s manual to specify that the gatebox and emergency dump controls are to be inspected periodically for condition, function and adjustment.

Recorded data from the aircraft indicated that the pilot had attempted to dump the hopper contents after becoming airborne – a move which would have achieved significant gains in climb performance. However, for unknown reasons, a complete dump was not achieved.

The performance benefits of quickly and significantly reducing an aircraft’s weight means that a proper functioning emergency jettison system to dump the contents of a hopper is vital. Pilots rely on the system in case performance is inadequate, particularly when taking off with a heavy load. Registered operators should ensure adequate ongoing maintenance and regular checks to maintain serviceability of the system.

As a result of the accident, the aircraft manufacturer is updating the maintenance section of the aircraft owner’s manual to specify that the gatebox and emergency dump controls are to be inspected periodically for condition, function and adjustment.

This accident also serves as an important reminder for pilots to monitor weather conditions like temperature and wind and to anticipate the potential adverse effects of local conditions on aircraft performance.

Read the final report: Collision with terrain involving Air Tractor AT-502, VH-LIK, 50 km east of Walgett Airport, New South Wales, on 5 November 2016

The Australian Transport Safety Bureau (ATSB) proudly sponsored the combined Australian Aviation Psychological Association’s (AAvPA) and PACDEFF symposium – held in Sydney across 7-9 November – to help foster the exchange of information and the advancement of knowledge and skills in the fields of psychology, human factors and crew resource management (CRM).

As the premier human factors and CRM event in the region, the ATSB’s Chief Commissioner, Greg Hood, and several of the Bureau’s human factors specialists, presented at the symposium on this year’s theme ‘maximising human performance for future systems’.

Chief Commissioner Hood said human factors are a key part of every aviation safety investigation.

“Thanks to the work and dedication of pioneers like the late Dr Rob Lee AO, human factors continues to be a core component of every ATSB safety investigation in the aviation, rail and marine modes of transport,” Mr Hood said during his keynote address.

“Dr Lee was the first human factors specialist to be appointed at the then Bureau of Air Safety Investigation when he joined the organisation in 1983. Dr Lee helped establish and develop the Bureau’s capability in human factors, systems safety and research.”

The ATSB is a world leader in human factors training, with more than 40 courses held since 2000 to educate those who are in a position to influence safety. In October, the ATSB’s latest human factors course was attended by several transport safety investigators and operators from New Zealand, Taiwan, Korea, Hong Kong and Kenya.

“It is a well-known adage that you can’t change the human condition, but you can change the conditions in which humans work,” Mr Hood said.

“Looking at our strengths and limitations, and highlighting that with respect to an occurrence, helps us accurately learn what has happened, why it happened, and how to prevent it.”

The ATSB’s SafetyWatch list, which comprises the most pressing safety priorities identified from its investigation findings, features several human factors concerns, including fatigue, data input errors and in-flight decision making.

Preliminary report into the runaway and derailment of a freight train in Devonport, Tasmania released.

The ATSB has released its preliminary report into the runaway and derailment of a freight train in Devonport, Tasmania on 21 September 2018. The investigation is continuing.

Investigators have found that the train derailed after it rolled away from a loading facility at Railton following its non-response to a series of remote commands.

The ATSB has determined that during loading, the last two wagons of the TasRail freight train were misaligned with the concrete loading chutes. To realign the train, the driver selected reverse on the remote control.

The train was unresponsive. The driver tried multiple times to reset the remote control equipment locally. Shortly after the driver decided to walk to the lead locomotive to do a cold restart at the rear of the locomotive, the train began to roll slowly towards Devonport.

The train did not respond to remote emergency stop commands through the removal of power to the transmitter and gradually gained speed as it rolled away from the loading facility at Railton. The driver alerted TasRail Train Control and the train was routed to a dead-end siding at Devonport.

The train collided with a concrete footing and fence at the end of the siding.  Two pedestrians received minor injuries from fence debris. The locomotive and eight wagons were significantly damaged.

Executive Director, Transport Safety Nay Nagy said ATSB investigators had interviewed a number of witnesses and collected relevant documentation about the train, the remote control system and the train network. 

“Investigators will now look at the design, serviceability and management of the locomotive, wagons, remote control system and the interface between them at the time of the accident and overall systems compatibility.

“Recovery controls such as runaway protection, emergency response systems and the detection of unauthorised train access will also be examined,” Mr Nagy said.

The investigation is expected to be completed in the second half of next year.

Read the preliminary report: Runaway and derailment of TasRail freight train, in Devonport, Tasmania, on 21 September 2018

Reminder of the limitations of night vision imaging systems, particularly when there are external light sources.

The release of the ATSB’s report into the terrain awareness warning system alert involving Eurocopter BK-117C-2, VH-SYB,  is reminder for pilots of the limitations of night vision imaging systems (NVIS) and night vision goggles (NVGs).

On 26 October, the helicopter took off under night visual flight rules (NVFR) from the Crookwell Medical Helicopter Landing Site with the pilot and aircrew member both wearing NVGs. Shortly after take-off, the helicopter entered unexpected low cloud and the pilot initiated the procedure for an inadvertent entry into instrument meteorological conditions.

As the helicopter’s climb reduced, the pilot lowered the helicopter’s nose to regain airspeed but inadvertently over corrected the pitch angle, triggering a terrain caution alert.  

The ATSB found the pilot was likely distracted, during a period of high workload, by the reflection of the helicopter’s anti-collision light against cloud, which was compounded by the use of NVGs.

Clearer guidance may have led to the conduct of a less risker IFR operation

NVGs can increase a pilot’s ability to see the horizon, terrain and objects, but it is important to remember there are also risks and limitations associated with their use. Ambient light, reflections and even the position of the moon, can reduce their effectiveness. NVG use needs to be supported by clear and robust processes from the operator.

During the investigation, the ATSB found there were also some ambiguities in the operator’s manuals about when to conduct NVFR operations with NVIS versus the use of instrument flight rules. Clearer guidance may have led to the conduct of a less risker instrument flight rules operation.

Information on the proper implementation and use of NVIS with NVGs and their benefits and limitations is available in the ATSB aviation research report Night Vision Goggles in Civil Helicopter Operations.

Read the final report: Terrain awareness warning system alert involving Eurocopter BK 117C-2, VH-SYB, near Crookwell, New South Wales, on 21 October 2016

The Australian Transport Safety Bureau (ATSB) has recognised respected Australian aviation author and editor, Macarthur Job OAM, by dedicating its new media studio in his honour, having spent more than half a century promoting aviation safety.

Earlier this year, the ATSB developed an in-house capability to provide media outlets with video and audio content for inclusion in their news coverage on transport safety investigations. The studio, which is used to produce broadcast quality TV and radio material, is located within the Bureau’s central office in Canberra.

ATSB Chief Commissioner Greg Hood officially named the facility the Macarthur Job Studio during a ceremony on 30 October, attended by his widow, Esma Job, along with three of his five children.

“When it came to naming our studio, Mac’s name came to mind immediately,” Mr Hood said, shortly after unveiling a wall plaque that detailed Mr Job’s esteemed career.

“Mac was a pioneer of aviation safety messaging in Australia, editing the principal safety promotion publication of Department of Civil Aviation’s Air Safety Investigation Branch – the Aviation Safety Digest.”

“For 14 years, Mac edited and contributed to the Digest, known in aviation circles as the ‘crash comic’, and he later became a highly regarded author on aviation safety with his highly acclaimed Air Crash and Air Disaster book series.”

Mac, who passed away in August 2014 aged 88, was invited to become a member of the prestigious Guild of Air Pilots and Air Navigators in 1983, through his work as editor of the Aviation Safety Digest. He was also awarded the Medal of the Order of Australia for his services to promote aviation safety in the 2003 Queen's Birthday honours.

Chief Commissioner Hood said the recognition and preservation of our transport safety investigation heritage is very important for the ATSB.

“I am deeply honoured to be able to dedicate our studio in memory of Mac,” Mr Hood said.

“The legacy of his professionalism and skills in amplifying important safety messaging derived from accident investigations, will always be remembered by the ATSB.

“The Macarthur Job Studio is an important capability for the ATSB – we can provide the media with broadcast quality content to help ensure our safety messaging is seen and heard by those in the aviation, marine and rail industries, and the general public.”

In addition to the investigation report and still imagery, media outlets can now download video and audio content directly from the ATSB’s website for most of the high-profile complex investigations.

A number of journalists have provided the ATSB with some positive feedback on the new studio, saying that the readily available content saves valuable time during the production of news reports.

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.