Human factors have long played a role in the life of Finland’s Safety Investigation Authority Human Factors Investigator, Dr Hannu Hanninen.

From a basketball scholarship to the United States in his early 20s to a doctorate on one of the worst maritime disasters of the 20^th Century, the 1994 sinking of the Estonia in the Baltic Sea, human factors continue to dominate his life.

Dr Hanninen, 51, is in Australia to participate in the Australian Transport Safety Bureau’s Human Factors for Transport Safety Investigators course, along with other safety investigators from around the world.

Human Factorsis a scientific discipline primarily concerned with the interaction between humans and the socio-technical systems with which and in which they work.

Dr Hanninen believes people who find themselves involved in accidents are not generally risk takers. “It is among the normal work of people where we tend to find failures,” he said.

“As investigators, we don’t just look at the accident, but at the work of people, to search for what produced a failure. It is not difficult to learn who made the final mistake. The bigger question is how did it come to that.

“Investigations might look at systems, engineering and process, but ultimately accidents occur because of the human element.”

He says exploring the human factors in accident investigations is fundamental to understanding how and why something happened.

Human factors played a role very early in the career of the former Finland junior national basketballer when he spent a year in the United States on a basketball scholarship at North Idaho College.

“Basketball was important to me but I quickly realised that the Americans had so many good players,” he said. “I was grateful for the opportunity but I moved on.”

After undergraduate study in organisation and management, Dr Hanninen, was inspired to pursue a career in accident investigation after the 1996 grounding of the Sea Empress, off the coast of Pembrokeshire in Wales.

The single hulled oil tanker hit rocks in a channel, holing her below the waterline. About 72,000 tonnes of light crude oil spilled into the sea, devastating bird and marine life and the Welsh coast.

Dr Hanninen says he is in Australia to learn about our way of investigating accidents, our human factors challenges and how our people work. “I can already see that your roles are more specific,” he said. “In Finland, our office is more multi-tasked.”

He says Australia’s no-blame attitude to investigations is similar to Finland’s. “This is a critical element in getting to the truth, as is having that separation between a police and a safety investigation,” he said.

While in Australia he hopes to pursue the opportunity for Finland’s Safety Investigation Authority to use the ATSB’s laboratory for ‘special’ investigations. “We don’t have our own technical laboratories. We could get material shipped to Australia within a few days. Geography is not a problem.”

In the meantime he is missing the other human factors in his life: his wife and eight-year-old identical twin daughters.

The Australian Transport Safety Bureau has reinforced a warning to pilots involved in aerial application after a spate of wirestrikes in the past month.

ATSB Chief Commissioner Greg Hood says pilots need to be extra vigilant with the crop spraying season ramping up as we move into summer, with reports of a particularly busy season for aerial agriculture.

“Wirestrikes are always a major issue for pilots involved in aerial application work,” Mr Hood said.

“With this season, it appears to be an even bigger issue. We’ve had five wirestrike incidents reported to us in the past few weeks. There is no doubt that with an increase in operations, the risk goes up dramatically.”

The ATSB published its Aerial application safety 2015–2016 year in review only last month. It showed wirestrikes to be the most common cause of accidents and serious incidents in aerial application between May 2015 and April 2016.

“Aerial application operations are inherently risky,” Mr Hood said “They involve low-level flying, high workloads and obstacles such as power lines and uneven terrain.

“Pilots have a high workload to navigate these hazards, and have a shorter reaction time if they encounter an issue and need to respond accordingly. But if pilots are working in areas of known wires, the hazard is manageable.”

The ATSB is also investigating a fatal aerial application accident near Walgett, NSW on Saturday, 5 November 2016. The cause of the accident is not yet known.

Safety meetings

The Aerial Application Association of Australia (AAAA) is currently holding Air Improvement Meetings (AIM) for their members around the country. In response to high seasonal demands during the 2015–2016 season, AAAA is holding additional breakfast safety meetings focusing on safety. Wirestrikes will be a key focus of these meetings.

Strategies developed by the AAAA and the ATSB to help pilots manage the risk of wirestrikes include:

• ensuring you are physically and mentally fit to fly
• setting client expectations so that they are clear that safety comes first
• conducting a thorough briefing and study a detailed map of the area before the flight
• conducting an aerial reconnaissance before spraying and conduct an extra aerial reconnaissance before the clean-up run
• reassessing the risks when plans change
• avoiding unnecessary distractions and refocus when distracted
• being aware of vigilance limitations
• not relying on your ability to react in time to avoid a wire
• actively look for and remind yourself of wires
• being aware of and managing pressures
• having a systematic approach to safely managing wires.

More information

Avoidable Accidents No. 2 - Wirestrikes involving known wires: A manageable aerial agriculture hazard

ATSB research report (AR-2016-022) Aerial application safety 2015-2016 year in review

Safety investigators from around the world will converge in Canberra this month to take part in the ATSB’s Human Factors for Transport Safety Investigators course.

Participants from Indonesia, Finland, New Zealand, Taiwan, Bangladesh, Singapore, Nauru and Vietnam will join Australians for an overview of human factors in safety-critical systems in the aviation, marine and rail industries.

ATSB Manager International Richard Batt says demand for the course, run twice per year, is always high.

“The ATSB is a leader in the application of human factors to transport safety investigations and is well placed to share its extensive knowledge,” Dr Batt said.

“The course was originally designed for ATSB staff but we recognise our commitment to improving safety investigations internationally in aviation, marine and rail industries.”

Dr Batt said human factors comprise the effects of physical, psychological and environmental factors on human performance in different task environments.

“This is a multi-disciplinary science that applies knowledge about the capabilities and limitations of human performance to all aspects of the design, manufacture, operation and maintenance of products and systems.

“After any accident or incident, a thorough operational and technical investigation is essential to determine what happened. Often it is only by investigating humans factors at both the operational and organisational level that it can be determined how and why events occurred.

“I should reiterate that in any ATSB investigation, we do not seek to lay blame or apportion liability. We incorporate this important philosophy throughout all aspect of the course.”

The course will cover issues such as perception, memory, attention, situational awareness, decision making, fatigue, stress, workload, ergonomics, safety culture as well as aviation, marine and rail case studies.

Presenters at the course come from the ATSB, the Australian Maritime Safety Authority, Macquarie University as well as private organisations Humanology, Flight Medicine Systems, Convergent Safety and Westwood-Thomas Associates.

ATSB senior research analyst Dave Wilson is working on a research investigation that will raise awareness of potential weather-related risks among pilots and also examine the effectiveness of rules that have been in place for more than 30 years.

Weather planning rules in Australia are unique compared to countries in Europe and North America. Because weather in Australia is generally good, risks are very low. But when weather is unsuitable for landing, these differences can have a real-world effect on aircraft operations. It is these effects that Dave’s research aims to quantify.

A number of unforecast weather episodes relating to flights into major Australian airports have led to unforeseen diversions, holding and, in some cases, landing below published safe limits. Dave’s research is seeking to understand how the reliability of weather forecasts affects the ability of flight crew to conduct safe landings.

“I want to help decrease the likelihood of pilots being exposed to unexpected and unsuitable conditions for landing,” Dave said. “The likelihood of an accident happening because of conditions unsuitable for landing is low. But in making it even lower, the probability of a major accident happening reduces considerably.

“Initially I’m looking at Mildura and Adelaide airports. At Mildura, 99 per cent of the time, the weather is suitable to land a large aircraft. But based on the data I’ve looked at, there is still a remote possibility you may have an unreliable forecast. With the volume of air traffic, this could affect up to four aircraft per year.

“If you look at Adelaide, the chances of a single flight crew being exposed to an unreliable forecast are lower. However, when you take into account fluctuations in weather reliability, and the aircraft traffic arrival patterns (around 50,000 per year), the potential to result in a catastrophic accident increases. That’s what we want to avoid.

“If you’re in the air and you get to the point of last safe diversion—where you’ll be committed to landing at the planned destination—if the current forecast predicts marginal conditions, questions are raised as to whether continuing to the planned destination or diverting to an alternate destination should be required. This scenario has been a particular focus of this research.”

Dave has a vested interest in his research. Several actually. He’s a pilot who first flew solo when he was a 15-year-old student at Caringbah High in Sydney—well before he could legally drive. The opportunity of subsidised flying with the Australian Air Force Cadets was too good to knock back. He has since flown aerobatics out of Bankstown Airport but has undertaken little flying over past two years while pursuing this research.

Dave also has degrees in Aeronautical Engineering and Physics from Sydney University. It was there he attended a guest lecture by Pierre Blais from the Directorate of Defence Aviation and Air Force Safety (DDAAFS), which set him on a path to the ATSB.

“It was then that I thought investigating aviation safety would provide the ultimate career path for me. I find it both meaningful and challenging,” Dave said.

The research was initially going to secure Dave a Master’s degree. But he is now upping the ante and aiming to pursue a Doctorate. A stumbling block is finding reviewers with sufficient expertise in a related field. When you’re breaking new ground, this is often the case.

After first working at the Department of Infrastructure as a vehicle compliance engineer, Dave came to the ATSB to embrace his love of aircraft, engineering and how things work. Now with six years under his belt, Dave is also considering his future. “I’m happy as long as I’m being challenged,” he said. “But after this research is completed, I wouldn’t mind also undertaking a broader range of transport safety investigations.”

Research on Adelaide and Mildura aerodromes is expected to be published by the end of 2016. Progressive reports for each major aerodrome in Australia and four of our remote island aerodromes (Norfolk, Cocos, Christmas and Lord Howe) will be progressively released over the next year or two.

If you hold a current Australian ATPL and CPL licence and have worked as an Australian charter or airline pilot in the past 12 months, we would like to hear from you.

The online survey will take around 15 minutes to complete. The results will establish a benchmark for the state of aviation safety in Australia. Responses will assist the ATSB to identify areas in Australian aviation safety that can be targeted for development.

All responses will be anonymous. We’ll publish our analysis of the responses in aggregated form on the ATSB website.

Complete the online survey.(Opens in a new tab/window)

The Australian Transport Safety Bureau (ATSB) is concentrating on the risk of wildlife strike during the 2016 Airport Safety Week.

Airport Safety Week, from 17–21 October, is a safety campaign that is specifically tailored to engage with employees and contractors working on an aerodrome.

ATSB Chief Commissioner Greg Hood says wildlife strike statistics provide a reminder to aircraft and aerodrome operators to be aware of the hazards posed to aircraft by birds and non-flying animals.

“Occurrences involving aircraft striking wildlife remain the most common aviation occurrence reported to the ATSB,” Mr Hood said. “Strikes with birds continue to be a significant economic risk for aerodrome and airline operators and a potential safety risk for pilots.”

Last year, 1775 wildlife strikes were reported to the ATSB, 97 per cent involving birds.

“The growth of reporting wildlife strike since the Transport Safety Investigation Act was introduced in 2003 has especially helped the ATSB to better understand the nature of birdstrikes, what the major safety risks are and where they lie,” Mr Hood said. “This has helped everyone in the aviation industry to better manage their safety risk.”

Larger bird species and flocking birds have the potential to do the most damage to aircraft. Compared to birdstrikes, animal strikes are relatively rare. The most common animals involved are hares and rabbits, kangaroos, dogs/foxes and wallabies.

There are a range of activities that can be undertaken to reduce the risk of wildlife strike.

Wildlife hazards should be assessed as part of serviceability inspections, wildlife patrols, runway inspections, and wildlife counts. Where a hazard is identified, it should be addressed through active management or by communicating the hazard to ATC or pilots.

It may be necessary to use the ATIS, a NOTAM, a note in Enroute Supplement Australia (ERSA) or a Birdwatch Condition Report to adequately communicate the hazard.

If a wildlife strike occurs, a strike report form should be completed and sent to the ATSB within 72 hours, including as much detail as possible.

Early morning, late afternoon, and after rainfall are key times for removing potential wildlife. Prioritising areas requiring dispersal should be based on airport operations, aircraft movement activity, and the distribution of high and moderate risk species.

Position of a wildlife controller should in most circumstances ensure that the wildlife are encouraged to fly or move away from aircraft movement areas and not across them.

There should be a focus on manoeuvring areas, and a variety of tools and techniques should be used to prevent habituation.

Australian Transport Safety Bureau (ATSB) Chief Commissioner Greg Hood today welcomed international visitors to the 19th Marine Accident Investigators Forum in Asia (MAIFA) conference in Canberra.

MAIFA is a non-profit organisation dedicated to promoting safety at sea and preventing marine pollution through the exchange of ideas, experiences and information acquired in marine accident investigations.

“I’m delighted to welcome participants to Canberra and I look forward to a fruitful exchange of ideas,” Mr Hood said.

“Australia’s reputation for high quality and rigorous investigations makes it uniquely placed to assist with transport safety in the Asia Pacific region.

“The ATSB has an active program of regional engagement with other transport safety agencies, over and above that required by our international obligations.”

As well as investigating marine accidents and incidents in Australia, the ATSB provides technical assistance to a range of countries in our region.

Nation’s participating in the MAIFA conference are Cambodia, the People’s Republic of China, Hong Kong, Japan, the Republic of Korea, Malaysia, New Zealand, Singapore, Thailand and Vietnam.

Australian Transport Safety Bureau communications manager Carl Fellows has put his demons to bed after finishing the famous Hawaii Ironman on his third attempt.

The Ironman World Championship at Kona on Hawaii’s big Island is billed as the toughest one-day, multi-sport endurance event in the world.

Few athletes know the truth of this like Carl.

The Ironman comprises a 3.8km ocean swim, a 180km ride through Kona’s lava fields and a 42.2km marathon. It’s hot, humid and windy.

After twice not finishing the event, in 2004 and 2009, Carl completed 2016 Hawaii Ironman in 13hrs 1min, after struggling with stomach issues for much of the run.

“I really thought I had the gut issues sorted this time,” Carl said. “I had a great swim, was conservative on the bike but struggled right from the start of the run.

“I used a different electrolyte drink from my two previous attempts and spent time acclimatising in the University of Canberra’s environment chamber. I’d done the training and was confident I had covered all bases.”

After a 1hr 2min swim and 5hr 22min ride, the run turned ugly. Instead of a 3hr 30min marathon, the course proved character-revealing with Carl battling on for a 6hrs 25min marathon.

“I had issues as soon as I started running,” Carl said. “If my heart rate went over 90bpm, I’d start throwing up. So it was lots of walking and stopping. I also had back spasms which I think were triggered from the vomiting.”

Carl is a talented athlete who qualified for Hawaii after finishing third in his age group in 9hrs 37min at Port Macquarie’s Ironman Australia in May, including a 3hr 23min marathon. A time in the low 10 hours was a reasonable expectation at Hawaii.

But Hawaii is famous for chewing up even the best professional athletes.

“I think somehow I’ve upset the big island,” Carl said. “It doesn’t like me. This was personal. I finished, but I don’t think I’ll be back.”

As the national transport safety investigator, the Australian Transport Safety Bureau deals with reports of many different types of events—some of these involve self-harm.

Many of these result in loss of life, with a tragic ripple effect among family, friends and colleagues. That ripple can also extend to people who become involved inadvertently, such as train drivers or air traffic controllers.

World Suicide Prevention Day, on 10 September, is an opportunity to connect, communicate and care—three words at the heart of suicide prevention.

So how do we do this? There are six key steps.

1. Reach out. Ask them directly if they are thinking about suicide. This shows you care and they’re not alone.
2. Listen to them. Let them talk. They will often feel a great sense of relief that someone wants to talk to them about their darkest feelings.
3. Check their safety. Stay with them, if you can. And remove the means of suicide.
4. Decide what to do and take action. Talk about what you can do together to keep them safe. And don’t agree to keep it a secret.
5. Ask for a promise. Thoughts of suicide may return, so ask them to promise to reach out and tell someone.
6. Get help. This may be through a GP or a counsellor, psychologist or social worker. It could be through a school counsellor. And there’s always 000. Community health centres may be able to help, as could crisis supports services such as Lifeline and Kids helpline. See support from family and friends, youth group leaders, a sports coach, a priest, minister of religious leader.

We also need to reconnect with those who we’ve lost contact with. Today—and everyday—is R U O K Day. So check in with friends, loved ones, mates and colleagues and ask the question: Are you okay?

For more information, visit Lifeline Australia(Opens in a new tab/window) or R U O K(Opens in a new tab/window).

The ATSB says pilots continue to collide with known wires in aerial application, including agricultural spraying, spreading and firefighting.

The Australian Transport Safety Bureau says pilots continue to collide with known wires in aerial application, including agricultural spraying, spreading and firefighting.

The ATSB’s Aerial application safety 2015–2016 year in review found wirestrike was the most common cause of accident and serious incidents in aerial application between May 2015 and April 2016.

Wirestrikes (where an aircraft hits a wire such as a powerline) caused 11 accidents and serious incidents in the 12-month period. Other types of accidents and serious incidents were engine failure or malfunction (6), collision with terrain (3), controlled flight into terrain (2) and runway excursion (2).

Most wirestrikes involve wires that the pilot was already aware of. Often, they involve wires which the pilot has flown several times before that day.

With their flying operations very close to the ground, aerial application pilots are well aware of the dangers of wires. The ATSB says pilots need to know the location of wires in the area to be sprayed through maps, talking with landowners and locals, and through aerial reconnaissance before operations commence.

Spraying patterns need to be organised with the wire locations in mind, and pilots need to maintain focus during their flying task, and use continuous reminders of the presence of wires. When plans change or the spray pattern differs such as for clean-up runs, pilots need to redo their aerial reconnaissance of wires.

Although there has been a slight growth in the number of accidents over the past three years, there were considerably fewer accidents each year in the past decade than in the previous 25 years.

Aerial agriculture has the second highest accident rate per million hours flown across the operation types, behind non-VH-registered recreational aeroplanes.

Aerial application operations are inherently risky, involving low-level flying, high workloads and obstacles such as power lines and uneven terrain.

Read the ATSB research report (AR-2016-022) Aerial application safety 2015-2016 year in review