Now in its fourth year, Rail R U OK Day is a collaboration between the TrackSAFE Foundation and R U OK? which encourages all rail staff to look out for one another during life's ups and downs by asking “Are you OK?” and really listening to the answer.

Rail staff play an important role in keeping the travelling public safe. Conducting work on or near a railway track can be dangerous and rail staff need to be fully focused on the work they are doing.

“There is a considerable momentum behind trains – they don’t stop quickly, so anyone working on track needs to have a clear mind with no distractions,” said Mr Hood. “Today’s Rail R U OK? Day is the perfect opportunity for you to discuss with your work mates any concerns or worries you might have. A breakdown in the communication or management of a worksite by someone when their mind is elsewhere could leave themselves and other workers vulnerable to hazardous situations.”

Visit www.ruok.org.au/rail-r-u-ok-day(Opens in a new tab/window) for more information on the Rail R U Ok? campaign.

The national R U OK? Day will be held on 13 September where everyone will be encouraged to ask their family, friends and workmates “Are you ok?”

Find out about our ‘Safe work on rail’ initiative at SafetyWatch.

This initiative aims to reduce call sign confusion events where similar sounding or near identical flight numbers have been used to communicate with air traffic controllers within the same airspace or at the same airport.

A scheduled passenger flight’s call sign commonly comprises of the airline’s name or moniker as a prefix followed by the flight number. In Emirates’ case, an example of their previous call sign is ‘Emirates 406’ – the airline’s regular Dubai to Melbourne service. However, with the introduction of the alpha-numeric format, this call sign has now become ‘Emirates 1CR’ (pronounced as “Emirates One Charlie Romeo”).

ATSB Chief Commissioner Greg Hood said Emirates’ first flights in Australian airspace using the alpha-numeric call sign format occurred on 25 March.

“The ATSB is supportive of those initiatives designed to improve transport safety and we congratulate Emirates on their introduction of alpha-numeric call signs in Australia for selected flights,” said Mr Hood. “We continue to encourage all airlines and aircraft operators to use call sign de-confliction strategies to help prevent call sign confusion incidents from occurring.”

Alpha-numeric call signs are now being used more broadly by a number of other airlines operating in congested European and Middle East flight information regions.

Their appointments, announced today by the Deputy Prime Minister, the Hon Michael McCormack MP, commenced on 20 March 2018 and will run for a further two years.

The ATSB’s Chief Commissioner Greg Hood said the reappointments are excellent news, both for the Bureau and for transport safety in Australia.

“Ms Walsh has over 30 years’ experience in policy development, regulation and safety management at both the Commonwealth and state levels,” said Mr Hood. “She has 15 years’ experience in the transport sector, initially as Executive Director of Strategy in the NSW Office of the Coordinator General of Rail, as Chief Executive of the NSW Independent Transport Safety and Reliability Regulator, and more recently as Chair of the National Transport Commission.”

Ms Walsh has specialist expertise in transport safety, occupational health and safety, risk management and the regulatory framework governing transport operations in Australia.

With over 40 years’ experience in the aviation industry, Mr Manning was first appointed as a Commissioner of the ATSB in March 2015. In the early 1970s, Mr Manning was an air traffic controller and then became a pilot for Qantas from 1975 until 2008 where he held the position of Chief Pilot and Group General Manager Flight Operations.

“Mr Manning flew several Boeing types gaining a B767 command in 1989,” said Mr Hood. “He was a check and training captain throughout the 1990s and was president of the Australian and International Pilots’ Association from 1999 until 2002.

“The work of both Ms Walsh and Mr Manning on the Commission has been exemplary,” said Mr Hood. “We’re fortunate to have them with us, working to make transport safer in Australia.”

More information on ATSB's Commissioners can be found here.

In addition to releasing the status of an investigation on its dedicated investigation web pages, the ATSB has also made available detailed information about its investigation phases and methodology.

ATSB Chief Commissioner Greg Hood said the changes were designed to provide a greater level of transparency into the work of the national transport safety investigator.

'The ATSB is a world class transport safety investigator and all of our investigations are undertaken in a meticulous and thorough manner, in accordance with both national and international legislation and standards. While our legislative obligations prohibit the release of restricted information during an active investigation, we strive to provide as much transparency as possible during an investigation.'

Mr Hood noted that the ATSB has traditionally provided more insight into its investigations than many international counterparts, particularly regarding the provision of estimated timeframes for each investigation.

'The dynamic and multifaceted nature of investigations can affect timeframes, which are always provided as an estimation.

'We understand that the length of time it takes to conduct a thorough investigation can sometimes generate frustration and uncertainty for directly involved parties such as next-of-kin, and for the interested general public.

'Australia actually performs very well against international investigation timeframes, particularly with  aviation investigations where our overall completion timeframes were assessed by the International Civil Aviation Organization as being around half of the global average.'

Mr Hood said investigation timeframes are impacted by two primary factors—available resourcing and the unpredictable and often complicated nature of serious incidents and accidents.

'It is important to note that, even if the timeframe of an investigation is extended, if the ATSB discovers a critical safety issue during an investigation we immediately bring it to the attention of relevant parties to be addressed.'

To better reflect the dynamic and multifaceted nature of investigations, the ATSB has now amended its web pages to reflect an expected completion date as a quarter, rather than a month.

Those who would like to be kept informed of ATSB releases can subscribe via the ATSB website.

This is particularly important in the traditionally male sector of science, technology and engineering and maths (STEM), which is the foundation skill set for many ATSB Transport Safety Investigators.

ATSB Transport Safety Investigator Sarah Fien said her experiences working in STEM-related fields has brought her immense satisfaction.

“There are so many professions that require an understanding of STEM. You never know where it is going to take you,” Sarah said. “Developing analytical and enquiring thought processes can be helpful in a wide variety of careers.”

Before starting at the ATSB, Sarah worked in the IT industry as a programmer and project manager, a flight instructor, charter pilot and competed in aircraft aerobatics.

There are so many professions that require an understanding of STEM. You never know where it is going to take you

“STEM opens up a world of possibilities. Work that is interesting and challenging can drive a purposeful life,” she said.

Working as a Transport Safety Investigator provides Sarah with an opportunity to use a range of her STEM-related skills.

“An investigation I found personally rewarding was a runway excursion involving a Cessna 550, VH-FGK, at Lismore Airport, NSW, on 25 September 2015. This provided an opportunity for me to apply my maths programming skills and undertake hands-on data analysis,” said Sarah. “It was satisfying to be able to use my skill set to determine that the parking brake had remained engaged for the take-off run, which reduced acceleration and caused a nose-down moment that prevented the aircraft rotating.”

ATSB Chief Commissioner Greg Hood said International Women’s Day provided an opportunity to pause and take stock of progress in gender parity.

“The ATSB is proactively working to build its gender balance,” said Greg. “We currently have 12 established females transport safety investigators. Many of our female staff members, including those working in our operational support teams, are part of our leadership team. I am also particularly pleased to have the support of a very experienced female ATSB Commissioner in Carolyn Walsh,” Mr Hood said. “Just a few weeks ago, I was also delighted to welcome four new female Transport Safety Investigator recruits to the ATSB.”

For information on International Women’s Day visit the website(Opens in a new tab/window)

The ATSB has launched nine investigations into rail occurrences in Queensland since becoming the single national transport safety investigator for rail on 1 July 2017. To support this expanded responsibility, the ATSB signed an agreement with the Queensland Government last year to facilitate its investigation of incidents and accidents on the metropolitan and regional passenger, and freight rail networks in Queensland.

The Queensland Government has now provided further support to the ATSB, through the contribution of equipment that can be used to measure track geometry when investigating rail occurrences, such as derailments.

A dual gauge continuous digital track geometry device was presented to ATSB Executive Director of Transport Safety Mr Nat Nagy by the state Department of Transport and Main Roads General Manager Mr Dennis Walsh on Monday 29 January.

The device includes two track measuring trolleys which are for use on 610mm and 1067mm rail track gauge, as well as the related hardware and software to enable the capturing, saving and analysing of the measured data. The gauge-specific nature of the trolleys means they are most useful for investigations in Queensland, Western Australia and Tasmania.

The ATSB will now be able to measure track geometry independently

Mr Nagy said the device would increase the efficiency of investigations into derailments, as the ATSB will now be able to measure track geometry independently. “In the past, the ATSB has relied on either obtaining information from the operator or occasionally engaging a track surveyor to undertake measurements,” Mr Nagy said.

Mr Nagy said an example of where the device could have been used was during the onsite phase of the investigation into the derailment of coal train EF01 near Duaringa, Queensland, on 24 January 2018.

“As part of this investigation, the ATSB worked with the operator to manually measure the track. In the future, the ATSB will be able to more effectively perform these measurements with the added benefit of being able to convey the information in real-time from the site to the office.”

Mr Walsh said the handover of the device to the ATSB marked another milestone in the transfer of the rail investigation services from the Department to the ATSB.

“It gives us great pleasure to know this device will be put to good use by the ATSB, as rail safety continues to remain a top priority for our Department.”

Mr Walsh said the Department looked forward to continuing its partnership with the ATSB. “Our relationship continues to grow stronger as we work together to prevent rail incidents and accidents throughout Queensland.”

A train driver had to emergency-brake to avoid hitting passengers from an evacuated train.

The ATSB has completed its investigation into a 2014 incident near Kilbride, New South Wales in which passengers were brought off a stranded train without adequate measures being taken to keep them safe.

At 1137 on 22 May 2014, NSW Train XPT passenger service NT33 was travelling from Paterson to Kilbride. The track is a single standard-gauge line that mostly carries a mix of passenger and freight trains, and there is a crossing loop at Kilbride to allow trains to pass each other.  As the train approached the loop at a speed of 118 kilometres an hour, the driver observed a bus at a road level crossing up ahead and realised that, beyond that, there were people on the track walking down towards him.

A disabled coal train had delayed an earlier passenger service (V938), and the passengers had been detrained to reach alternative road transport. The train crew of V938, however, had not complied with the Australian Rail Track Corporation network rules when detraining the passengers from their train.

At the time, Sydney Trains and NSW Trains were in a transitional period, assuming operation and maintenance functions that had previously been held by RailCorp. A services contract and protocols had been developed to identify the roles, responsibilities and limits of authority of personnel throughout the change, but on the day of this incident, there was confusion and assumptions among the crew as to who had done what in regards to ensuring appropriate track protection.

All of this had resulted in the crew unknowingly placing the passengers in the path of the oncoming NT33.

We cannot afford to make assumptions when it comes to safety.

The driver of NT33 immediately made an emergency brake application and sounded the horn continuously. The train finally came to a stand approximately 80 m short of the people.

There were no reported injuries as a result of the incident, but this near-miss shows the importance of strict adherence to recognised detraining and track protection procedures when transferring passengers from a stranded train to a safe place.

The investigation also found that key operational staff in NSW Trains and Sydney Trains continued to operate under RailCorp legacy systems, even though documented transitional arrangements had re-established lines of responsibility and authority. This misunderstanding of roles, responsibilities and limits of authority by operational employees likely contributed to inadequate communication between critical safe working positions.

ATSB Executive Director of Transport Safety Nat Nagy says it is essential that safety systems are fully developed and understood by all.

“Thankfully, no one was injured,” Mr Nagy said. “But this shows that we cannot afford to make assumptions when it comes to safety.”

Read the final report: Near hit with detrained passengers on track, at Kilbride, New South Wales, on 22 May 2014

A serious incident shows the importance of understanding aircraft systems and cockpit procedures.

This serious incident involving an Airbus A320 on approach to Perth Airport has illustrated ATSB’s ongoing safety concerns in relation to pilots not effectively managing their aircraft’s flight path when unexpected events arise during the approach to land.

This incident occurred on 19 February 2016, when a scheduled passenger service was arriving from Denpasar, Indonesia. During the cruise, the captain’s flight management and guidance computer (FMGC1) had failed, and the flight crew had elected to use the first officer’s duplicate systems.

The flight crew were conducting an instrument landing system (ILS) approach to Perth Airport. They made a number of flight mode changes and autopilot selections - normal for an ILS approach with all aircraft operating systems available, but some of which relied on data from the failed FMGC1.  As a result, the autothrust system commanded increased engine thrust and the crew, who had not expected this response, elected to conduct a go-around. An increased crosswind then prompted air traffic control to effect a change of runway to a runway without a precision instrument approach procedure.

The approach and landing phases of flight are amongst the highest of workload for flight crews…

The unresolved system failures, the conduct of the go-around, and the subsequent runway change all resulted in a significant increase in cockpit workload. This, combined with the crew’s unfamiliarity and preparation for the non-precision instrument approach to the new runway, hampered their management of the next descent.

During the approach to the new runway, the crew descended the aircraft earlier than prescribed, but believed that they were on the correct flight path profile. They became concerned that they could not visually identify the runway, and focused their attention outside the aircraft. This distraction meant that the crew were not effectively monitoring the descent and the captain descended the aircraft below the segment minimum safe altitude.

As the aircraft continued to descend, the air traffic controller received a “below minimum safe altitude” warning for the aircraft. The air traffic controller alerted the crew to their low altitude and instructed them to conduct a go-around. The crew then conducted another approach and landed without further incident.

ATSB Chief Commissioner Greg Hood said that the approach to land is one of the most critical phases of flight, and stressed the importance of flight crews understanding their aircraft systems and adhering to cockpit control, monitoring and communication procedures to ensure a stabilised approach during the approach and landing phases of flight.

“The approach and landing phases of flight are amongst the highest of workload for flight crews, and domestically and internationally where we see the highest accident rate” Mr Hood said. “It’s a complex operation at the best of times, but when something unexpected occurs such as a failure of an aircraft system in-flight, it can add substantially to flight crews’ workload. It is critical that flight crew fully understand their aircraft systems and how they will respond in a degraded mode, and adhere to cockpit protocols and procedures to ensure a stabilised approach resulting in a safe landing. In this case, there was considerable added complexity for the flight crew as a result of adverse weather, and an air traffic control change to a runway without a precision approach.”

“The ATSB urges all flight crew to ensure that they understand their aircraft systems, and how the aircraft will respond in a degraded mode, and to adhere to cockpit protocols and procedures to ensure a safe approach and landing. If there’s any doubt or confusion, or if the stable approach criteria is not being met, communicate it, and never hesitate to conduct a go-around.”

Read the final report: Descent below segment minimum safe altitude during a non-precision instrument approach involving Airbus A320, PK-AXY, 17 km WSW Perth Airport, Western Australia on 19 February 2016

The report brings together information over ten years, from 2007 to 2016, to provide insights into current and possible future trends in aviation safety, and takes a detailed look at the accidents and serious incidents in 2016 for each type of aircraft operation.

ATSB Chief Commissioner Greg Hood said the report provides important information for the aviation industry, manufacturers and policy makers, as well as the travelling and general public, on aviation transport safety.

“By comparing accident and occurrence data across aviation operations types, the ATSB is able to identify emerging trends, further areas for research and take steps to recommend pre-emptive safety actions,” Mr Hood said. “While I am grateful that there were fewer fatalities in the aviation sector in 2016 than in any previous year recorded by the ATSB, any loss of life is a poignant reminder of the importance of our work to better understand the multilayered causes of aviation safety occurrences.

In 2016, nearly 230 aircraft were involved in accidents in Australia, with 291 involved in a serious incident (an incident with a high probability of an accident). Across the different operation types:

• commercial air transport operations experienced one fatality from 15 accidents
• general aviation experienced 10 fatalities from 119 accidents
• recreational aviation had 10 fatalities from 63 accidents.

Nine of the 15 fatal accidents involved aeroplanes. Three helicopters and two powered weight shift aircraft were also involved in fatal accidents. There were no fatalities in either high or low capacity regular public transport (RPT) operations.

The report also provides insights into an emerging trend in transport safety—the increased use of remotely piloted aircraft (RPA). In 2016, RPAs surpassed helicopters as the second highest aircraft type for reported accidents; however, there were no collisions with other aircraft, fatalities or serious injuries relating to RPA reported to the ATSB. While the consequences of an accident involving an RPA have been low to date, their increased use, and possible interactions with traditional aviation, will continue to be monitored closely by the ATSB.

Mr Hood said the report highlights the importance of effective and timely reporting of all aviation safety occurrences. “This is not just for the potential of initiating an investigation, but to allow further study and analysis of aviation transport safety,” Mr Hood said.

For more information on the increased use of remotely piloted aircraft and its safety implications read the ATSB report: A safety analysis of remotely piloted aircraft systems 2012 to 2016: A rapid growth and safety implications for traditional aviation

The ATSB is urging day-VFR pilots to plan to arrive at their destination at least 10 minutes before last light and to have a realistic ‘plan B’ to use when it becomes apparent that the intended flight cannot be completed in daylight hours.

The ATSB’s investigation into the fatal accident of a Robinson R22 helicopter reflects an ongoing problem in aviation – some pilots are continuing to fly into conditions they are not equipped for and not trained for.

The accident occurred on 7 April 2016, when two Robinson R22 helicopters, each carrying a pilot and a passenger, were returning to Mossman, Queensland from a day spent fishing to the north. They had taken off late in the afternoon, intending to fly back directly, but weather and winds had slowed their progress and they stopped at Cooktown in order to refuel.

The consequences of losing visual reference while flying are usually fatal...

They departed Cooktown at around last light, intending to track via the coast. Neither pilot was qualified to fly at night or in low-visibility conditions that would require instrument flying. Additionally, the helicopters were not equipped with an artificial horizon instrument and lacked other equipment for flight at night under Australian regulations.  As the flights progressed, the light from the sun continued to decrease and there was no moon.

The coastal route between Cooktown and Mossman has few settlements and from halfway, most of the coastline is part of the Cape Tribulation section of the Daintree National Park. It is a remote area with little or no ground lighting.

The passenger in one of the helicopters, concerned by the darkness, suggested landing on the beach. The pilot did not answer but it appeared to the passenger that they might be descending to land. The passenger saw the ocean more clearly, just before the helicopter impacted the water.

The passenger was able to release himself from the helicopter and reach the surface, and the tide carried him to the beach where he made contact with campers.

Unaware of the accident, the other helicopter continued to Mosman.

A search was initiated and the missing aircraft was located two days later, about 400 m offshore, in about 10 m of water. The pilot was not located.

Stuart Macleod, Director Transport Safety at the ATSB says that accidents involving visual flight at night are an ongoing concern in Australian aviation.

“The consequences of losing visual reference while flying are usually fatal,” said Macleod. “Over the years, we have investigated over thirty accidents there were the result of visual flight at night. Those accidents have resulted in over fifty fatalities.”

The dangers of flying at night are the subject of the ATSB’s report ‘Visual flight at night accidents: What you can’t see can still hurt you.’  The report provides studies on different night-flight accidents along with useful information on knowing one’s own personal limitations.

Read the final report, AO-2016-031: Collision with water in dark-night conditions involving Robinson R22 helicopter, VH-YLY, 6 km south of Cape Tribulation, Queensland, 7 April 2016.