An incident in which a freight aircraft flew below the minimum permitted altitude has highlighted the value of having a clear and, where appropriate, shared contingency plan.

The incident occurred on 17 June 2016, as the Boeing 737-376 was arriving on a freight service to Launceston, Tasmania from Melbourne. Air traffic control (ATC) advised the crew that, based on the latest automated weather observations, rain showers and overcast cloud were impacting visibility.

After arriving overhead Launceston, the flight crew proceeded to conduct an instrument approach to the runway but, owing to the weather conditions, they could not see the runway, and elected to conduct a missed approach and go around for a second approach.

After they had climbed away from the runway, the captain initiated a left turn to reposition the aircraft for a second approach. While responding to a call from the airport groundsman, the captain handed control of the aircraft to the first officer (FO). The captain instructed the FO to maintain the turn, but did not advise where they were turning to or onto what heading. There had been no discussion about how the aircraft would be manoeuvred on completion of the missed approach.

The resulting flight path resulted in the aircraft entering an area with a minimum permitted altitude of 5,800 ft., but it had only climbed to about 4,400 ft. In response, air traffic control issued a safety alert for terrain and instructed the crew to climb the aircraft above the minimum safe altitude.

The aircraft was never in immediate danger of colliding with terrain, but its operation over an area and at an altitude less that that prescribed for safe flight was cause for concern.

Stuart Macleod, Director Transport Safety at the ATSB says this is not the first time they have seen this sort of problem. “The approach and landing phase of a flight brings a substantially increased workload,” said Macleod. “In fact, that is the phase of flight traditionally associated with the highest accident rate.”

A similar incident occurred in 2011, when an Airbus A320 descended below the minimum permitted altitude after conducting a go-around at Avalon Airport in Victoria. The ATSB investigation found that flight crew, despite recognising the potential need for a go-around, did not plan for a return to the runway. Indeed, the workload associated with the execution of the go-around prevented them from planning the return to land until they’d levelled at 3,000 ft.

“Both incidents showed the safety benefit of intervention by air traffic controllers,” said Macleod. “But it’s far better to have things right without being corrected. The importance of good planning and good communication around the approach and landing phases of a flight is one of the key messages in our SafetyWatch list of concerns.”

The ATSB is encouraging operators and flight crew to consider including appropriate missed approach considerations, such as intended flight path, crew actions, terrain clearances and ATC requirements into their approach briefings.

For more information on managing flightpath during the approach to land, visit the ATSB’s SafetyWatch page.

The ATSB has released a research report, Safe work on track across Australia: Analysis of incident data.

ATSB Chief Commissioner Greg Hood said the report examines serious issues demonstrating where rail safety needs to be improved.

“Issues relating to safe work on track have been on the ATSB’s list of safety priorities since the list’s inception in 2012,” said Mr Hood. “The effectiveness of the current track work risk controls requires continual improvement.”

The effectiveness of the current track work risk controls requires continual improvement.

The ATSB continues to receive notification of safe work incidents involving worksite protection arrangements. These notifications suggest the existence of broader safety issues associated with work on track that continue to present a level of risk to worker safety.

The report was developed after ATSB researchers reviewed 12,146 occurrence records from all state and territory rail safety regulators for the period July 2009 and July 2014. Of these, approximately 15 per cent were to found to be associated with work on track.

The report identifies eleven categories of occurrences. The most common occurrence type involved situations where insufficient or incorrect types of protection were put in place.

Before publication, the report was released as a draft for consultation with valuable input being received from the public and industry, including from the Office of the National Rail Safety Regulator.

Mr Hood said that the he hoped that the report would provide a catalyst to the rail industry as a whole to continue to improve safety on Australia’s rail network.

“This new report identifies the most common events exposing track workers to safety risks,” said Mr Hood. “People working in the rail industry will be able to use this as a guide, helping them target the most common and dangerous problems that we’re seeing in our examination of the data.”

ATSB research report RI-2014-011: Safe work on track across Australia: Analysis of incident data

ATSB Manager of International, Dr Richard Batt, said the course was an example of the ATSB’s close collaboration with its counterpart in Indonesia, a relationship which is of significant benefit to both agencies.

“This is the second MSIC we’ve provided to our colleagues in Indonesia,” said Dr Batt, “and, once again, it’s received a very positive reception.”

The ATSB investigators, Mike Hooley and Tristan Shandy, presented to 25 attendees. Over the course of three days, they gave instruction on marine safety investigations and the casualty investigation code, including techniques in interviewing and analysis.

The course is part of the ongoing Indonesia Transport Safety Assistance Package (ITSAP). ITSAP was developed between Australia and the Government of Indonesia to address key Indonesian transport safety priorities. The main elements of the ATSB's contribution to the program have been to deliver training and support for investigators from the ATSB's Indonesian counterpart agency, the NTSC.

This has included the ATSB providing staff dedicated to various capability-building projects, funding ATSB training courses in Indonesia and Australia, and opportunities for aviation, marine, and rail investigators to work with their ATSB counterparts.

The cooperation between the ATSB and the NTSC is one of the key elements in ensuring lasting transportation safety for the people of Indonesia and Australian travellers to Indonesia.

“We’re working together to build a safer transport sphere throughout the region,” said Dr Batt.

Each year, the ATSB publishes SafetyWatch, its list of safety priorities across the marine, rail and aviation modes.

These priorities are identified from investigation findings and from the thousands of safety notifications received by the ATSB each year.

ATSB Chief Commissioner Greg Hood urged the transport industry to give heightened attention to the risk areas identified in this release.

“Of concern are the areas of safety priority that have had to be carried over from last year’s list,” said Mr Hood.

“As the national transport safety investigator for aviation, marine and rail, the ATSB is uniquely positioned to identify significant safety issues—and, all too often, we are seeing the same safety issues arising again and again.”

In addition to modified or expanded priorities, this year’s list has identified two new areas of concern. The first is an issue that affects safety in all modes of transport: fatigue.

Mr Hood said experiencing fatigue and its effects on performance is an area of concern not managed consistently across the transport industry.

“Everyone has experienced fatigue at some point, but in the transport industry, where there’s often high pressure to deliver on-time services, fatigue can have very real, and potentially dangerous implications,” Mr Hood said.

“Fatigue can have a range of adverse influences on human performance, such as slowed reaction time, decreased work efficiency, reduced motivational drive, and increased variability in work performance.”

The second new issue to make the SafetyWatch list is based on a relatively new and increasingly popular technology: remotely piloted aircraft systems (RPAS), commonly known as drones.

“The number of RPAS in Australia has increased exponentially,” said Mr Hood, “and, with it, the number of near-encounters with manned aircraft has also increased. Thankfully, there have been no reported collisions in Australia to date, but we are working to manage any potential risks through our research and education.”

Through the SafetyWatch initiative, the ATSB provides information about each safety concern, as well as strategies to help manage risk areas, and links to safety resources. 

“SafetyWatch is designed to improve the transport community’s awareness of these safety priorities,” Mr Hood said. “I urge industry to take the time to look over what we’ve found, in the interest of improving transport safety.”

ATSB Chief Commissioner Greg Hood said the report described a year of significant change and evolution.

“The report outlines in detail our achievements and performance across the reporting period, and acts to further reinforce the ATSB as a trusted, world-class transport safety investigation agency,” Mr Hood said.

During the year, the ATSB received more than 17,000 incident and accident notifications, and completed 59 complex investigation reports and a further 110 short investigation reports.

The Annual Report describes changes, both in the transport arena, and within the ATSB.

One of the key developments has been the increase in use of remotely piloted aircraft systems (RPAS) or drones. In March 2017, the ATSB released its first research report on RPAS, describing how a steep rise in the number of RPAS in Australia has been accompanied by a similar rise in safety occurrences.

“RPAS is an emerging risk that requires close monitoring as the number of these aircraft continues to grow,” said Mr. Hood.

The ATSB itself also continues to grow and change. The past year has seen the Bureau become the national rail safety investigator, assuming responsibility for investigating all rail incidents and accidents for the states and territories. It also embarked upon a landmark recruitment drive and implemented a rigorous new strategy to address a backlog of investigations.

“We have taken significant steps to not only allow us to better address our key performance indicators in the future, but to improve and advance Australia’s transport safety investigation capabilities.”

There have also been changes in the way that the ATSB approaches its primary objective.

“We have become more selective,” explained Mr Hood, “investigating those accidents and serious incidents that have the greatest potential for safety lessons. In addition, we have pursued greater interaction with operators and regulators, and expanded our communications, education and promotion in a further effort to improve transport safety.

“I look forward to continuing to learn and grow in my role as Chief Commissioner of the ATSB. The years ahead will be exciting and challenging for the ATSB, and I am confident that the professionalism and capability of our people will ensure we remain a world-leading transport safety investigation agency.”

ATSB Annual Report 2016-17

Named after Australian aviator, businessman and decorated World War I pilot, Oswald Watt, the medal is awarded for ‘A most brilliant performance in the air or the most notable contribution to aviation by an Australian or in Australia’ by the Royal Federation of Aero Clubs of Australia.

On stage for the award presentation, the ATSB’s Chief Commissioner, Greg Hood, said he was delighted to read such an extensive and decorated citation outlining Mr Lloyd’s achievements and contributions to aviation.

“The presentation of the Oswald Watt Gold Medal to Peter is befitting for such an icon of Australian aviation,” said Mr Hood. “Turning 97 this December, Peter’s enthusiasm for air safety, and for Safeskies, remains unabated. He maintains a youthful energy for the betterment of the aviation industry, despite no longer flying or driving.”

Mr Lloyd’s extensive decorations and awards include Companion of the Order of Australia (AC) for eminent service to the aviation industry in 2016 and the Officer of the Order of the British Empire (OBE) for service to aviation and the motor industry. He is also one of only three Australians to have received the Fédération Aéronautique Internationale (FAI) Gold Air Medal.

Last night’s award is the second time Mr Lloyd has received the Oswald Watt Gold Medal, having originally been awarded the honour in 1969. Past recipients include Sir Charles Kingsford Smith MC, AFC, Sir Hudson Fysh KBE DFC, Sir Reginald Ansett, Dick Smith, Andy Thomas and Dr Paul Scully-Power.

“Peter’s support for flying training and flying safety has been untiring, unwavering and outstanding,” said Mr Hood. “On behalf of everyone at the ATSB, I would like to extend my sincere congratulations to Peter. He is a true gentleman and I applaud him for his continuing contributions to aviation.”

Airport Safety Week, a collaboration between the Australian Airports Association (AAA) and the NZ Airports Association (NZ Airports), is a safety campaign specifically tailored to engage employees and contractors working on an aerodrome.

A number of activities are being held at aerodromes throughout the week to encourage staff to think about safety, including the national Wear Personal Protective Equipment (PPE) to Work Day, which raises awareness of the appropriate use and maintenance of PPE in the aviation workplace.

Aerodrome operators are also encouraged to invite all staff to participate in a Foreign Object Debris (FOD) Walk, where they will be given the opportunity to walk a section of the aerodrome to scan for FOD and raise awareness of this vital part of airport safety.

ATSB Chief Commissioner, Greg Hood, who attended this year’s launch at Parliament House, said Airport Safety Week is about encouraging everyone who works in the airport environment to be vigilant of safety at all times.

“This annual safety campaign is also a great opportunity to show the travelling public that the global aviation industry always puts safety at the forefront,” said Mr Hood.

“The theme of this year’s Airport Safety Week – ‘one airport, one team’ – reinforces that, as we are all working together, every day, to keep you safe when you fly.”

For more information on Airport Safety week, visit www.airportsafetyweek.com(Opens in a new tab/window)

The ATSB invited representatives from the Accident Investigation Commission (AIC) of Papua New Guinea (PNG) and the National Transportation Safety Committee (NTSC) of Indonesia to attend the Safeskies Conference being held in Canberra. The guests took the opportunity to also visit the ATSB headquarters in Canberra on Tuesday.

ATSB Manager International Richard Batt said that the sponsored visit was an excellent opportunity to expand upon the programs of cooperation and capability-building that Australia enjoyed with its neighbours.

“We’re building an increasingly strong transport safety-investigation community throughout the Asia Pacific region,” said Dr Batt. “Through the Indonesia Transport Safety Assistance Package and our Memorandum of Understanding with Government of PNG on cooperation in the transport sector, we’re enabling a greater flow of skills and knowledge between investigators.”

The visitors were AIC Chief Commissioner Mr Hubert Namani and Commissioner and Caretaker CEO Mr David Tawae, and Mr Ray Nurcahyo and Ms Ucu Suherman of the NTSC. Mr Nurcahyo is the head of Aviation Investigation Sub-Committee and Ms Suherman is a Human Factors Investigator.

During their visit to the ATSB offices, the visitors met with Chief Commissioner Greg Hood, as well as with other ATSB investigators to discuss the latest developments in transport safety. Part of the visit was spent receiving a briefing of the applications and implications of Remotely Piloted Aviation Systems in transport safety investigations.

“This ongoing collaboration and information-sharing is important,” said Dr Batt. “It allows all the organisations to pool their experience and insights, making us all more effective. This brings benefits, not only to the investigators, but also all the members of the public who travel throughout our region each year.”

The report, The Operational Search for MH370 records the search for MH370 and Australia’s work on the underwater search, including the ways in which the search area was identified, and how the search was conducted.

The Chief Commissioner of the ATSB, Greg Hood, said that the report demonstrated the extraordinary endeavours of people from around the world.  

“This was an unprecedented endeavour and there has been an extraordinary response from the global community,” said Mr Hood. “There were contributions of expertise and resources from private business and organisations, agencies from different Governments, and from private individuals.”

While the resting place of the aircraft has not yet been located, the search was conducted consistent with the highest of standards of safety and professionalism, to the credit of everyone involved.

“The search inspired dedication from so many,” said Mr Hood. “I am proud to have worked with people of such commitment.”

The ATSB’s report was accompanied by the release of the CSIRO’s final MH370 research report. The search for MH370 and ocean surface drift – Part IV confirms the effectiveness of the March-April 2014 surface search in key areas.

“Our deepest sympathies remain with those who lost loved ones on MH370,” said Mr Hood. “It remains a great tragedy, and we wish that we could have brought complete closure to the bereaved. I hope, however, that they can take some solace in the fact that we did all we could do to find answers. Governments from around the world contributed to the search, with extraordinary expertise committed to the task.''

The Operational Search for MH370

Commissioner Hart’s reappointment by the Hon Darren Chester MP, Minister for Infrastructure and Transport will commence on 1 October 2017, and will continue for a further two years.

Chief Commissioner of the ATSB Greg Hood said that Commissioner Hart’s reappointment was excellent news, both for the Bureau and for transport safety in Australia.

“Commissioner Hart was first appointed to the ATSB in July 2009, and he has proven to be a highly credible and respected Commissioner” said Mr Hood. “His maritime knowledge and experience are well established, and his time with the ATSB has not only provided him with important insights into the other modes of transport, but has also enabled him to positively contribute to investigations in the aviation and rail sectors.”

As one of three Commissioners working with the Chief Commissioner, Commissioner Hart helps to define the strategic direction of the ATSB and provides a high level of quality assurance to all of the agency’s published investigation reports.

Commissioner Hart has over 40 years’ experience in the shipping, oil and gas industries. His qualifications include a Master Mariner Class One qualification, and holds an MBA. He has held management positions with BP Shipping in Melbourne, London and Chicago.

From 2006 to 2009, he held the position of General Manager of the North West Shelf Shipping Service Company, based in Perth. In that position, he was responsible for the safe shipping of natural gas from north-western Australia to Asian and other global customers.

He has been Chairman of Maritime Industry Australia Ltd, Australia’s peak maritime association, since 2008.

“Commissioner Hart’s work at the ATSB has been exemplary,” said Mr Hood. “We’re fortunate to have him with us, working to make transport in Australia safer.”

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