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

Objective interpretation of runway surface conditions can reduce risk.

The ATSB is advising pilots to be conservative when relying on pilot reports for runway surface conditions, in particular, when the conditions are considered damp.

The ATSB’s investigation into the reduced braking effectiveness during landing of a Boeing 737 at Christchurch International Airport, 11 May 2015, highlights the how misperceptions of runway surface conditions can lead to runway excursions.

After touch down on runway 29, the Boeing 737 did not decelerate as expected during the later stages of the landing roll. The crew overrode the autobrakes, applied hard manual braking and retained the use of reverse thrust until the end of the runway.

The aircraft stopped about 5 metres from the end of the runway.

The ATSB found that, due to an increased workload, the crew misperceived the runway surface conditions, believing it to have a damp surface condition when in fact it was wet. This resulted in the aircraft’s expected landing performance not being achieved.

Pilots are advised to apply a conservative approach when relying on other pilot reports for runway surface conditions, in particular, when the conditions are considered damp.

ATSB Executive Director, Transport Safety, Mr Nat Nagy said the incident demonstrates how the subjective nature of runway surface reports and braking actions reports can contribute to the risk of a runway excursion.

“There is little standardisation between how pilots, industry and regulators describe runway surface conditions,” Mr Nagy said. “Information provided to pilots is often from multiple sources, with undefined terminology that may only be relevant to a certain time or type of aircraft.

“To overcome this, the International Civil Aviation Organization will be adopting the United States Federal Aviation Administration’s (FAA) runway condition assessment matrix in November 2020.”

The Civil Aviation Safety Authority (CASA) have advised the ATSB they anticipate aligning their runway condition definitions with ICAO post 2020.

“Until then, pilots are advised to apply a conservative approach when relying other pilot reports for runway surface conditions, in particular, when the conditions are considered damp,” Mr Nagy said.

Additionally, the ATSB found, along with the FAA, that the 15 per cent in-flight safety margin applied to actual landing distances may be inadequate under certain runway conditions. CASA has advised they intend to evaluate this finding and update the corresponding advisory material accordingly.

Read the final report: Reduced braking effectiveness during landing involving Boeing 737-800, VH-VOP, at Christchurch Airport, New Zealand, on 11 May 2015

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.”

ATSB Chief Commissioner Greg Hood has awarded outgoing Director of Defence Aviation and Air Force Safety (DDAAFS), Group Captain John Grime, with a certificate of appreciation for his contribution to improving aviation safety within the Australian Defence Force.

The presentation ceremony, held at the ATSB's head office in Canberra on 21 June 2018, also afforded an opportunity for Mr Hood to meet the incoming DDAAFS, Group Captain Nigel Ward, who has been promoted from the rank of Wing Commander for the position.

 “The ATSB recognises and thanks Group Captain Grime for his service since 2016, and I wish him well in his new role heading up 92 Wing at RAAF Base Edinburgh,” Mr Hood said. “There has been a close relationship between Defence Aviation and Air Force Safety (DAAFS) and the Bureau for many years, with an ongoing memorandum of understanding supporting our co-operation. I am looking forward to continuing this relationship and working closely with Group Captain Ward.”

 Last year, the ATSB seconded a DAAFS investigator resource for six months, which offered both organisations an immeasurable learning opportunity. During his secondment, Lieutenant Commander Darryl Whitehead was afforded the opportunity to deploy to a number of accidents including to a fatal Robinson R22 helicopter accident in Cloncurry, Queensland and to a double fatal Diamond DA40 accident in Jimboomba, west of Brisbane.

 “There are numerous subtle differences between the two agencies, however we are united in the common goal to improve transport safety,” Mr Hood said. “Underneath the different uniforms, we are essentially all cut from the same cloth. We are committed to investigating accidents and analysing occurrence data with the sole aim of preventing recurrence.”

At 10.50am on Saturday 9 June 2018, ATSB Chief Commissioner, Greg Hood, along with more than 90 other passengers landed at Brisbane Airport on board a specially painted Alliance Airlines’ Fokker 100, VH-FGB.

Their touchdown was exactly 90 years to the minute when Fokker F.VIIb/3m, called Southern Cross, and its four crew completed the first trans-Pacific flight from the USA to Australia.

As the historic records show, Charles Kingsford-Smith, the pilot-in-command of the Southern Cross, along with his co-pilot Charles Ulm, navigator Captain Harry Lyon and radio operator James Warner, took off from Oakland, California at 8.53am on 31 May, 1928 bound for their first stop in Hawaii. The tri-motor Southern Cross landed at Honolulu at 9.49am on 2 June and departed the following day at 5.20am on its second leg bound for Suva, Fiji.

Airborne for a staggering 34 and half hours, the Southern Cross landed in Suva’s Albert Park at 2.21pm on 4 June after flying around 5,000 kilometres.

After three days on the island, the Southern Cross left Fiji on its last leg to Brisbane at 2.52pm on 8 June, some 2,400 kilometres to the east.

Around eight and a half days after leaving Oakland, including over 83 hours in the air and covering about 11,670 kilometres, the Southern Cross landed at Brisbane’s Eagle Farm Airport at 10.50am on 9 June 1928, where they were welcomed by over 15,000 people.

“I am greatly honoured to have been on board for this significant historical flight,” Mr Hood said. “Today, we also flew in a Fokker, in the comfort and with the safety that ‘Smithy’, Ulm, Lyon and Warner would only have dreamed of 90 years ago. Their feat of safely completing the first trans-Pacific flight, set the bar high for aviation safety in Australia.”

Alliance Airlines, now the largest operator of Fokker aircraft in the world, is based at Brisbane Airport, not far from where the Southern Cross touched down 90 years ago.

“I would like to thank Alliance Airlines’ Chairman Steve Padgett for inviting the ATSB to be a part of the celebrations to mark a significant event in Australian aviation’s history,” Mr Hood said. “The ATSB is keen to see important events and achievements in aviation and other modes of transport maintained and acknowledged. In fact, we are currently preparing a number of historical air accident items that we have in our possession to be displayed prominently in the reception area of our Canberra head office.”

The original Southern Cross is on display in a special memorial near Brisbane Airport’s international terminal.

Promoting safety across the Australian helicopter industry, the ATSB has landed at Rotortech 2018 – the Australian Helicopter Industry Association's (AHIA) biennial conference and exposition.

Held at the Novotel Twin Waters on the Sunshine Coast across 24-26 May, Rotortech 2018 attracted more than 500 local and international delegates with interests in the helicopter industry.

ATSB Chief Commissioner, Mr Greg Hood, presented an overview of the Bureau and its role as the nation’s accident investigator to a large audience on day one of the three-day event. During his presentation, Mr Hood also discussed the trend in helicopter accidents in Australia over the past decade and provided an update on several active investigations.

"This was the first time the ATSB has spoken at a Rotortech in its current form," Mr Hood said. "I would like to thank Paul Tyrell, the Chief Executive Officer of the AHIA, for the invitation to engage with the association's members and visitors at Rotortech. I look forward to continuing to strengthen our relationship with the AHIA and its members, and for the ATSB to be involved in future Rotortech events.

"In the past decade, there has been 361 helicopter ‘accidents’ in Australia - that’s an average of about 36 accidents per year. As of last week, there's been seven helicopter accidents in 2018, two of which have been fatal. We are now approaching almost the halfway mark for the calendar year, and we're on track to recording a below average accident rate, which is a great sign."

A highlight of his presentation, Mr Hood jointly launched 'Don't push it, land it' , important safety messaging that encourages helicopter pilots to make a safe precautionary landing if they encounter an abnormal situation in flight.

"In conjunction with the AHIA and the Civil Aviation Safety Authority, I was pleased to launch ‘Don’t push it, land it’, which encourage pilots to use their helicopter’s unique ability to land almost anywhere if it’s not right in flight," Mr Hood said. "Whether they inadvertently fly into instrument meteorological conditions or if something concerns them with their aircraft, our message is clear, make a safe precautionary landing and sort it out on the ground.

"I would personally like to acknowledge and thank Dick Smith, who was the driver and advocate for the ‘Don’t push it, land it’ safety messaging. Over the coming months, the ATSB, CASA and the AHIA will continue to work together in an effort to reduce the rate of avoidable helicopter accidents."

Inside the exposition hall, the ATSB showcased the vital work of its transport safety investigators at its display stand alongside the promotion of 'don't push it, land it'.

More information on ‘Don’t push it, land it’.