Aircraft operators and organisations involved in aviation safety will soon have access to a new method of submitting written notifications to the ATSB of aviation safety matters.

This method will allow operators and organisations to report out of their own safety management systems or reporting software and directly transfer accident and incident notifications to the ATSB notification system.

This new option is set to significantly improve the way aviation transport safety matters are reported to the ATSB.

How it works

To ensure that accident and incident data reported to the ATSB is compatible with the ATSB’s notification system, we have developed an ‘XML schema’ that is available upon request through the ATSB website.

The schema will provide a framework for organisations and software vendors to develop and automate accident and incident reporting solutions in a format compatible with the ATSB notification system.

Draft schema

Before we roll out the schema, we’re offering an opportunity for interested parties to review and evaluate a draft version.

We’re particularly keen to engage with software vendors and operators of safety management systems who are looking to either update existing systems or build new systems that are capable of using the ATSB’s schema for reporting accidents and incidents.

Once the final schema is released, the ATSB will provide a section on its website where software vendors and safety management system providers can apply to have their compatible reporting systems listed as being ‘ATSB Reporting Compliant’.

This listing option will be conditional on the ATSB validating that the outputs of any reporting system are fully compliant with schema and the ATSB’s notification system.

Reporting options

The ATSB’s current options for reporting incidents and accidents include a web form, email, fax, post and electronic formats. Within the next 12 months, the ATSB will move towards only accepting electronic formats for the submission of written accident and incident notifications.

This means that aircraft operators and organisations will eventually need to report aviation transport safety matters to the ATSB via their compatible reporting solution or through the ATSB’s web notification form. The ATSB will keep you updated on the new reporting requirements over the coming months.

Compliance

Irrespective of the schema’s implementation, users need to ensure that they are compliant with all aspects of the aviation accident and incident reporting requirements of the Transport Safety Investigation Act 2003 or any other applicable statutory instrument.

Prior to receiving the schema details, users will need to accept the license terms and conditions associated with its use, which will be supplied by the ATSB.

Licencing

A licence for use of the schema will be provided in accordance with the terms of Creative Commons Licence Attribution CC BY 3.0(Opens in a new tab/window).

More info

To get a copy of the draft schema or for more information, please contact the ATSB’s Manager of Reporting, Short Investigations & Research at atsbinfo@atsb.gov.au.

The ATSB recently renewed an Agency Arrangement with the Department of Infrastructure as part of the Australian and PNG governments’ cooperation in the transport sector.

The Agency Arrangement supports the program of cooperation between the ATSB and the PNG Accident Investigation Commission (AIC), with the aim of improving transport safety in PNG through a number of activities with funding from an Australian aid initiative.

The program supports capability building activities with the main objective of supporting the AIC to move closer to international standards and recommended practices in aviation safety investigation.

The ongoing relationship will result in a safer and more secure transport system for PNG citizens, visitors to the country, and people and assets moving into and out of PNG airspace.

The relationship means PNG will be better placed to realise its medium and long-term transport infrastructure development goals and build the country’s capability to manage its transport safety responsibilities.

A functional and appropriate PNG transport network will in turn enable economic growth that supports productivity, employment and access to basic services.

PHOTO: Department of Infrastructure Deputy Secretary Pip Spence and ATSB Chief Commissioner Greg Hood renew an Agency Arrangement

The Aviation Short Investigation Bulletin covers a range of the ATSB’s short investigations and highlights valuable safety lessons for pilots, operators and safety managers.

Released periodically, the Bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken. The Bulletin also highlights important Safety Messages for the broader aviation community, drawing on earlier ATSB investigations and research.

Issue 55 of the Bulletin features ten safety investigations:

Jet aircraft

• Engine shut down involving Boeing 787, VH-VKK
• Hydraulic leak involving Boeing 787, 9V-OFG
• Loading event involving Airbus A320, VH-VFN

Turboprop Aircraft

• Loading event involving Avions de Transport Régional ATR42, VH-TOX
• Depressurisation event involving de Havilland DHC‑8, VH‑XFP
• Wirestrike involving Cessna 441, VH-NAX

Piston Aircraft

• Wheels up landing involving Piper PA31, VH-ETW
• Engine failure and forced landing involving Jabiru SP500, 19-5503

Helicopter

• Collision with terrain during mustering involving Robinson R22, VH‑PFX

Near Collision

• Near collision involving Cessna 210, VH-SQT, and Gippsland Aeronautics GA8, VH-KNB

Australian aviation would be less safe without the means to confidentially report issues of concern.

“We have a powerful reporting culture in Australia,” says Elaine Hargreaves, the woman at the end of the line for the ATSB’s confidential reporting system known as REPCON.

“Whenever there is an incident or accident, the vast majority of operators will inform the ATSB, as required by law.

“REPCON differs from regular reporting in that it allows people with concerns about unsafe procedures, practices and conditions to inform the ATSB without being identified.

“It’s not dobbing. This is about solving issues and problems that could otherwise lead to compromised safety.”

Elaine says people contact REPCON because they know they can speak their mind without fear of recrimination, discipline or punishment from their employer, their union or their peers.

In April 2016 a reporter contacted REPCON to express a safety concern about flight crew exceeding the amount of time they’re allowed to fly on a regular basis.

The operator strenuously denied the allegation, saying they were anonymous and so non-specific that they could not realistically be investigated. The operator did however review its fatigue risk management requirements and discussed fatigue risks with pilots.

CASA, as the regulator, reviewed the REPCON and would consider the information provided as part of planned surveillance. CASA also encouraged the complainant to contact CASA’s confidential safety risk line to provide more specific details.

In January 2016 a reporter expressed a safety concern about fatigue management procedures for a ground operations controller.

It was a safety-critical role filled by one individual on an 11-hour shift allegedly with no rostered breaks. There was a risk that incorrect fuel and freight figures would be used due to the controller’s fatigue.

The operator subsequently undertook a detailed fatigue analysis, reviewed ground operations controller rosters and provided a report outlining follow-up.

CASA reviewed the matters raised in the REPCON and noted the operator’s response did not take into consideration reporting through the organisation’s safety management systems (SMS). Using the SMS can help identify areas where the operator should focus resources to reduce operations risk, including fatigue risk. CASA addressed the matter with the operator.

“These are just a few examples and many more can be found on the ATSB website,” says Elaine. “People don’t always like being told to change their system but the changes that are implemented out of REPCON reports are usually mutually beneficial to reporters and operators.

“We’re not trying to replace existing reporting systems but sometimes a confidential, external system is required because people may feel uncomfortable about being identified.”

Anyone involved in flight operations, and even passengers, can report a safety concern.

If you have any information which you consider may affect aviation safety contact REPCON on 1800 020 505 or submit a report online.

It’s never pleasant contemplating the next major rail accident but ATSB investigators need to be prepared for when it happens.

As part of our major accident preparedness, senior rail safety investigators will meet in Adelaide this week to stress test current investigation response plans to a major rail accident.

ATSB Manager of Rail Safety Investigations Tony Simes said the workshop will improve the way the ATSB responds to a future major accident.

“While rail safety has improved over the years, we want to ensure we’re able to respond quickly and efficiently should a major accident occur,” Tony said.

“Investigators from around Australia will take part in the workshop, including the ATSB, the Office of Transport Safety Investigations in NSW, and the Chief Investigator Transport Safety in Victoria.

“The workshop will also draw on investigator expertise from the numerous national emergency exercises in which the ATSB has been involved.

 “During the workshop, we’ll define the worst-case credible scenarios—what a major rail accident looks like—and formulate the most effective response to these scenarios.

“A key part of the workshop will also be determining the risks associated with responding to a major accident—what things might affect our ability to do our job. These risks include resource limitations and preserving evidence while working with other agencies/stakeholders."

The workshop will take place over Wednesday and Thursday this week. This is the first of a number of workshops to ensure the ATSB is prepared for responding to any major transportation accident.

In an uncompromising, timely and collective manner, the ATSB searches for truth to enhance transport safety.

In an uncompromising, timely and collective manner, the ATSB searches for truth to enhance transport safety.

In the 2015–16 financial year, the ATSB completed 44 aviation safety investigations and 90 short factual investigations. In the marine sector, it completed seven safety investigations while in the rail sector there were 19 safety investigations.

The ATSB does this with just 103 staff, half of whom are investigators.

So how do the investigators go about their work? The short answer is that it depends on what part of the investigation they are working on.

Laura Henwood is an ATSB Recorder Specialist, working mostly in the rail and marine sectors.

Recorders may have been damaged in an accident or incident so special precautions are used to ensure they make it back to the laboratory without losing any data.

In the lab, the information is retrieved and provided to the investigating team. A range of inputs along with images and video can be used to build a picture of the circumstances leading up to an accident or incident.

Heather Fitzpatrick specialises in aviation human factors.

It's difficult for some to understand how somebody with a lot of experience, say a pilot, can become involved in an accident. Why didn’t their experience save them?

By applying human factors principles, Heather can help explain not only what happened, but why. Because the worst of accidents can happen to the best of people.

Max Marton specialises in aircraft systems and their technical aspects.

He will attend an accident site and start piecing together the remains of an aircraft, some of which may be heavily fragmented.

Max may look at recorders, GPS systems, mobile devices, fuel systems and the engine and how it was performing prior to the accident. Other factors, such as crew history and the organisation behind them are also considered.

While an accident site provides evidence of what happened, it’s the ‘why’ that’s fundamental to the work of the ATSB and its mission to improve transport safety.

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Some things are just meant to be. For US-based underwater search specialist Andy Sherrell, one of those things was to work on the search for missing Malaysia Airlines Flight MH370.

When his daughter was born on 8 March 2014, the day Malaysia Airlines flight MH370 disappeared, Andy’s wife Renee suggested that was one search he was unlikely to be involved in.

Having already worked on several major underwater search, salvage and recovery operations, including Air France Flight 447 in 2009, Alaska Air Flight 261 in 2000, Egypt Air Flight 990 in 1999, Swiss Air Flight 111 in 1998, and TWA Flight 800 in 1996, Andy’s reputation had grown in the industry.

But the new father, on the other side of the world to the strange disappearance of MH370, was very interested in the loss, but had other ‘domestic’ priorities.

The reputation of the Florida Institute of Technology graduate in Ocean Engineering, however, would soon find its way to the desk of the Australian Transport Safety Bureau’s Program Director for the search for MH370, Peter Foley.

“I flew out to Australia and met with Peter and soon after began work on one of the most difficult search operations I’ve been involved in,” Andy said.

“The sheer size of the search area given the limited loss information, the remote, cold and extremely harsh patch of ocean—add in the deep and mountainous seafloor and this is an overall very challenging operation. But I’m confident the plane will be found.

“I think we’ve proven that the confidence in our search is high when you consider some of the items we’ve discovered and our very high coverage percentages.

“We systematically search the areas of highest confidence, then move to the next area, which then becomes the new area of highest probability.

“Just like when you have lost your car keys, once you have looked on the table and they are not there, you move to the next likely spot.”

Andy’s key role is managing quality assurance for the project. It began with the tender process and planning for the search and continues with reviewing the extensive sonar data.

“The search strategy working group determines areas for us to search,” he said. “My main focus it to make sure we search that area and cover it with a high degree of confidence.

“Once we finish searching an area we want to say with a hand on our heart that we have high confidence the aircraft is not in that area.”

Andy spends around four months of the year in total in Australia, usually around three weeks at a time, split between Canberra, Perth, and Fremantle.

His previous work has been more ‘shipboard and hands on’ but with his MH370 role, it’s more about the quality assurance across all the underwater search assets, which at times has been up to four vessels simultaneously.

He says the best aspect of the job is working with the team from the ATSB, with a common goal. “They are dedicated, focused and will do all they possibly can to find the plane,” Andy said.

“The worst aspect is being away from my family in the US. But I get looked after very well by my cobbers at the ATSB.”

Unfortunately, Andy has not been able to enjoy Australia’s iconic Vegemite on his toast in the morning. About five years ago he became allergic to the yeast in beer.

“Vegemite contains similar yeast to what’s found in beer. Really disappointing,” he said. Sarcasm, it seems, is an international skill.

In another year of growth in the aviation, rail and marine transport sectors, the ATSB has continued its role as Australia’s national transport safety investigator.

The 2015–16 year was the ATSB’s seventh as a fully independent safety investigator and, despite challenging fiscal circumstances, was able to complete a range of significant and comprehensive investigation reports.

This was in addition to supporting the secondment of a number of specialist staff to the continuing search for the missing Malaysia Airlines Flight MH370 and the reopened investigation into the Norfolk Island ditching accident.

This week, ATSB trainers are conducting Aircraft Accident Investigation Fundamental (AAIF) training in Vietnam.

This initiative is supported with funding from the Department of Foreign Affairs and Trade (DFAT), and the Australian Embassy in Vietnam through their Economic Diplomacy Fund.

The AAIF course being held in Vietnam forms part of the ATSB program of regional engagement, in this case assisting countries in the Asia Pacific to meet international standards for aviation safety investigation.

The AAIF course has been tailored for investigators from the Civil Aviation Authority of Vietnam (CAAV) and is being hosted at the CAAV facilities in Hanoi. The 5 day course includes investigation management, safety at the accident site, evidence collection, human factors, investigation analysis techniques and report writing.

Attending the course alongside the CAAV investigators are industry participants from Vietnam Airlines, VietJet, Jetstar Pacific, as well as commercial helicopter operators, aircraft maintenance organisations and the Vietnam Aviation Academy.

The course also provides an important opportunity for all participants to discuss investigation issues unique to Vietnam and develop relationships between agencies in order to improve safety.

Indonesian National Transportation Safety Committee (NTSC) flight recorder specialist Andreas Hananto is enhancing his flight data recovery and analysis skills during a placement at the Australian Transport Safety Bureau (ATSB).

Andreas manages the flight recorder facilities and leads the flight recorder team at the NTSC.

ATSB Manager International Richard Batt says the ATSB’s reputation for high quality and rigorous investigations makes it uniquely placed to assist aviation safety in the Asia Pacific region.

“This two-week placement will enable Andreas to further develop his skills in flight data recovery and analysis, and expand his knowledge of recorded data associated with Air Traffic Control systems,” Dr Batt said.

“The overview and introduction to Air Traffic Control/aircraft systems interface and data format will help equip him for his work in this vital area of aviation safety investigation.

“When Andreas returns to Indonesia he will be able put his newfound knowledge and skills to good use, helping to further improve Indonesian aviation safety.”

Dr Batt says the ATSB has a specific program of cooperation and capability building with the NTSC.

“We have an excellent relationship with Indonesia’s NTSC and have hosted two junior transport safety investigators earlier this year,” Dr Batt said.

“We are able to provide assistance through the Indonesian Transport Safety Assistance Package (ITSAP), supported by funding from the Australian Government Department of Foreign Affairs and Trade (DFAT).

“Cooperation between the ATSB and the NTSC is a key element in ensuring lasting transportation safety for the people of Indonesia and Australian travellers to Indonesia.”