Indonesian investigator at ATSB

Indonesian safety investigator Apib Prayogi can trace his journey to working at the Australian Transport Safety Bureau in Canberra to two tragic aviation accidents.

Indonesian safety investigator Apib Prayogi can trace his journey to working at the Australian Transport Safety Bureau in Canberra to two tragic aviation accidents.

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The first was the loss of Air France Flight 4590 from Paris to New York on 25 July 2000. All 100 passengers and nine crew members aboard the Concorde died when it crashed into a hotel on take-off. On the ground, four people were killed and one was critically injured. It was the only fatal Concorde accident during its 27-year operational history.

A few years later in junior high school, Apib was fascinated by a Discovery Channel documentary on the accident and, more importantly, the investigation that followed.

“I was very curious as to how the investigators did their detective work to uncover the cause of the crash,” Apib said.

It struck a chord in the mind of the young Apib such that when career consultants paid a visit in senior high school, aeronautical engineering was presented as an option that could lead to interesting work.

With (very) solid maths results at school, Apib completed a Bachelor of Aeronautical Engineering (2010) in Adisutjipto College of Technology, Jogjakarta, and then a Master of Aeronautical Engineering (2014) from the prestigious Institute of Technology, Bandung.

This led to Apib becoming a junior investigator with Indonesia’s National Transportation Safety Committee (NTSC).

The second accident was in March 2007 when a Garuda Indonesia Boeing 737 over-ran the runway while attempting to land at Yogyakarta airport in central Java. The accident claimed 21 lives, five of whom were Australian. The accident lead to the development of the Australian government Indonesia Transport Safety Assistance Package (ITSAP).

ATSB Manager International Richard Batt says the main elements of the ATSB's contribution to ITSAP is to deliver training and support for investigators from the NTSC.

“This includes the ATSB providing staff dedicated to various capacity building projects, funding ATSB training courses in Indonesia and Australia, and opportunities for aviation, marine, and rail investigators to work with their ATSB counterparts for extended periods,” Richard said.

“Our Indonesian colleagues learn much from us. But it’s not all one way. The programs that we develop are mutually beneficial. 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.”

Apib, 28, was selected as the first of two junior investigators who will spend time at the ATSB in Australia this year, thanks largely to his English language skills.

“I started learning English in junior high, where it is compulsory,” Apib said. “I continued into senior high and when I did my tertiary studies, most of the aeronautical engineering texts were in English.”

Apib is delighted with his time at ATSB, working with professional and highly committed staff and expanding his knowledge and experience.

“It’s like on-the-job training, especially with the short level (Level 5) investigations. We don’t have the kind of system and databases that you have here,” he said.

“I am learning how ATSB does its investigations, especially with its more advanced tools and laboratory. I already have a better understanding of how an investigation goes. And from that I can see how we can improve in Indonesia.

“We would like to have a system, such as you have at ATSB, which meets international standards. We will get there, but in my view it may take up to 10 years.”

Perhaps not surprisingly, Apib sees himself as a senior aviation investigator ‘in about 10 years’.

Married with a young daughter, Apib will continue to gain more qualifications, expand his knowledge and undertake more training.

In the meantime, he is grateful for the opportunity to work in Canberra at the ATSB, even if it is the middle of winter.

“I would like to thank Australia, the ATSB and the ITSAP program for this opportunity, and for assisting to improve our investigator qualifications and set up our flight recorder laboratory,” Apib said.

“I especially would like to thank Dr Soerjanto (NTSC Chairman) and Dr Richard Batt and the team in Level 5 investigations at ATSB. Everyone has been helpful and supportive and given me the opportunity to learn.”

Apib said he was also grateful to those who took him “out bush” for a first-hand encounter with kangaroos, koalas and a platypus!

Rail Safety Week 2016

ATSB Chief Commissioner Greg Hood has reinforced the 2016 Rail Safety Week message that rail safety is everyone’s responsibility.

Australian Transport Safety Bureau (ATSB) Chief Commissioner Greg Hood has reinforced the 2016 Rail Safety Week message that rail safety is everyone’s responsibility.

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The 11th Rail Safety Week will take place nationally from 15–21 August 2016.

“Rail safety is ultimately everyone’s responsibility, whether you are a member of the public, rail worker or rail operator,” Mr Hood said.

“If you are a passenger, stand behind the yellow or white line on the platform at all times. When on board a train, hold on to something, be sensible, pay attention and be alert—and courteous.

“At level crossings, trains can come at any time and from either direction so pedestrians and drivers—commercial and others—need to be fully aware of their surroundings.

“Mobile devices occupy much of our time these days, but getting that text away in a flash can result in tragedy.”

Mr Hood said the ATSB would be happier having fewer rail accidents to investigate, such as the fatal level crossing collision between a train and truck at Narromine in NSW in 2015. From its investigation, the ATSB identified areas of potential improvement related to road design, especially curved approaches before railway crossings.

Mr Hood said Rail Safety Week was not just about the public taking greater responsibility, but rail workers too.

“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,” he 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, government, road safety and police partners in promoting safety in and around the rail network.

Death and injury on rail networks are avoidable if people obey the rules and remain aware and alert at all times.

For more information visit Rail Safety Week 2016(Opens in a new tab/window) or the ATSB’s Safe Work on Rail You Tube video(Opens in a new tab/window).

Aircraft Operations Investigation

  • This position is open to international candidates.
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The Accident Investigation Commission (AIC) of PNG is seeking to recruit a suitable person for appointment to the position of Manager – Aircraft Operations Investigation.  

The AIC was established in 2010 and is responsible for meeting PNG’s international obligations for aviation accident investigation. This role is critical in leading the investigation into aviation incidents and accidents in PNG. The incumbent will lead a team of investigators to undertake investigations and will actively develop the accident investigation skills of the investigations team (including cadet investigators).

The position is jointly co-funded by the Accident Investigation Commission and the Papua New Guinea – Australia Transport Sector Support Program (TSSP), funded by the Australian Government.

The position description including qualifications, skills and experience required for the role is available from the TSSP website www.pngtssp.com(Opens in a new tab/window).

Applications should be submitted to ‘AIC Selection Panel, c/o PNG – Australia Transport Sector Support Program’ by email at: accidentinvestigation.AIC@gmail.com

Applications must be received by close of business on Friday 5 August 2016.

ATSB welcomes new Chief Commissioner

The ATSB Commission today welcomes Greg Hood who begins his five-year appointment as the second Chief Commissioner of the Australian Transport Safety Bureau.
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The ATSB Commission today welcomes Greg Hood who begins his five-year appointment as the second Chief Commissioner of the Australian Transport Safety Bureau.    

Greg has more than 35 years’ experience in the transport industry, beginning his career as an air traffic controller in the Royal Australian Air Force (RAAF). Greg has since had a wide range of operational, training and management roles across the civil aviation industry. Most recently, Greg served in senior roles in Airservices Australia and the Civil Aviation Safety Authority.

As well as being a glider and powered aircraft pilot, Greg is involved with a number of aviation bodies. He is a Fellow of the Royal Aeronautical Society, a Freeman in the Honourable Company of Air Pilots, and a Life Member of the Qantas Founders Museum. Before joining the ATSB, Greg was a Board Member of Safeskies Australia and Vice-Chair of the steering committee for the Civil Air Navigation Services Organisation’s (CANSO’s) Operations Standing Committee.

The Commission looks forward to the extensive experience and expertise Greg will bring to the ATSB, and transport safety investigations.

The Commission sincerely thanks previous Chief Commissioner Martin Dolan for his valuable leadership over the past seven years. Martin has overseen a number of major ATSB investigations that resulted in significant improvements to transport safety. These include the ATSB’s investigation into:

  • the uncontained engine failure of a Qantas A380 aircraft over Batam Island in 2010, which resulted in international safety improvements to Rolls-Royce engines and airframe certification standards for all aircraft
  • safety issues involving Queensland coastal pilotage, resulting in regulatory and operational improvements to pilotage operations
  • Sydney to Melbourne railway line that examined the safety of the rail track along with a systemic review of the track’s safety systems
  • the in-flight upset of a Qantas A330 in Western Australia that uncovered critical lessons for manufactures of complex safety systems.

Martin has strengthened the ATSB’s position as a national and international leader in transport safety. He played a critical role in reforming Australia’s rail safety investigations under a single national jurisdiction and oversaw the unprecedented search for missing Malaysia Airlines flight MH370.

The Commission wishes Martin the best in his retirement and looks forward to building on his success under Greg’s leadership.  

Pitch disconnect

As a result of the investigation into a Virgin Australia Regional Airlines flight sustaining a pitch disconnect while on descent into Sydney, the ATSB has identified a safety issue that needed to be highlighted before this investigation is completed.

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As a result of the investigation into a Virgin Australia Regional Airlines flight sustaining a pitch disconnect while on descent into Sydney, the ATSB has identified a safety issue that needed to be highlighted before this investigation is completed.

  • Inadvertent application of opposing pitch control inputs by flight crew can activate the pitch uncoupling mechanism which, in certain high-energy situations, can result in catastrophic damage to the aircraft structure before crews are able to react.

This interim report provides only the factual information and analysis associated with the identified safety issue and complements information already provided on an update on the ATSB website on 10 June 2014. New evidence may become available as the investigation progresses that will enhance the ATSB’s understanding of the occurrence.

Read the interim report: In-flight upset, inadvertent pitch disconnect, and continued operation with serious damage involving ATR 72 aircraft, VH-FVR, 47 km west-south-west of Sydney Airport, New South Wales, on 20 February 2014

Privacy Awareness Week 2016

The ATSB is a proud partner of Privacy Awareness Week (PAW) 2016. This year's PAW theme, Privacy in your hands, reinforces the message that organisations, agencies and individuals must be vigilant in maintaining a good understanding of their rights and responsibilities for the handling of personal information.
  • The ATSB is a proud partner of Privacy Awareness Week (PAW) 2016.

This year's PAW theme, Privacy in your hands, reinforces the message that organisations, agencies and individuals must be vigilant in maintaining a good understanding of their rights and responsibilities for the handling of personal information.

You can find out more about how we protect your privacy by reading our privacy policy, which is available on our website www.atsb.gov.au Our policy addresses the following issues:

  • the types of personal information collected and held by the ATSB (including sensitive information);
  • how and why we collect personal information;
  • how the ATSB stores personal information;
  • use and disclosure of personal information (including overseas disclosure);
  • how you can access and correct your personal information; and
  • how you can make a privacy complaint to us.

Of course, we are not the only agency that collects your personal information. Here are some tips from the Office of the Australian Information Commissioner(Opens in a new tab/window) to help you protect your own personal information:

  • Know your privacy rights
  • Read privacy policies and notices
  • Always ask why, how and who — this will help you to know how your personal information is going to be used
  • Check your credit report
  • Protect yourself online
  • Be aware of your mobile security
  • Use security software
  • Be careful what you share on social media
  • Don't leave your personal information lying around — make sure your records are properly destroyed
  • Beware of scams.

More information on your privacy rights is available at www.oaic.gov.au/paw(Opens in a new tab/window). You can also join the conversation by following #2016PAW on Twitter.  

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“Black Box” pioneer recognised

Inventor of the “black box” flight recorder, Dr David Warren AO, has been posthumously recognised with the prestigious Dr Edward Warner aviation award.

Named in honour of the first President of the International Civil Aviation Organization (ICAO), the award is presented by the ICAO every three years on behalf of all its member nations.

ATSB Chief Commissioner Greg Hood said the award recognises the outstanding contribution Dr Warren has made to transport safety.

“The ‘black box’, whether it is a flight data recorder (FDR) or cockpit voice recorder (CVR), contains critical information investigators need to determine the causal factors surrounding accidents and incidents,” Mr Hood said.

“Dr Warren’s pioneering efforts have significantly improved aviation safety and saved countless lives—the award is well deserved. Interestingly, the concept of flight recorders is now being utilised widely in other transport modalities such as rail and marine.

“The ATSB extends its acknowledgement of this achievement, and our appreciation on behalf of all of those who travel, to Dr Warren’s surviving children Jennifer, Peter and Graham. The ATSB also recognises the support provided to Dr Warren by his late wife Ruth, and daughter Meg, both of whom have passed away.”

The “black box” flight recorder was invented by Dr Warren in 1956. The flight recorders contain recordings of instrument data and cabin crew transmissions and conversations. In the event of an accident, the information on the recordings is invaluable to accident investigators trying to determine what happened and why.

Dr Warren passed away in 2010 at the age of 85. He was buried in a casket bearing the label "Flight Recorder Inventor; Do Not Open.”

Minister for Infrastructure and Transport Darren Chester today issued a statement welcoming the award.

New Chief Commissioner

The ATSB Commission has warmly welcomed the appointment of Greg Hood as the ATSB’s new Chief Commissioner from 1 July 2016.

The ATSB Commission has warmly welcomed the appointment of Greg Hood as the ATSB’s new Chief Commissioner from 1 July 2016.

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Greg brings to the ATSB more than 30 years’ expertise in transport safety, having most recently served in senior leadership roles with Airservices Australia and the Civil Aviation Safety Authority.

The Commission looks forward to working closely with Greg to continue the ATSB’s role in improving transport safety across the rail, maritime and aviation industries.

Greg will replace current Chief Commissioner Martin Dolan whose term expires on 30 June 2016.

Fumes events declining

The number of reported aircraft fumes and smoke occurrences involving high capacity aircraft in Australia is trending significantly lower, according to an ATSB report published today.

The number of reported aircraft fumes and smoke occurrences involving high capacity aircraft in Australia is trending significantly lower, according to an ATSB report.

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Fumes and smoke events, which generally occur in the cockpit or cabin of larger passenger aircraft, are required to be reported to the ATSB.

During the April to June 2015 quarter, there were only 42 fumes and smoke events reported to the ATSB, down from 90 in the same quarter a year before.

The decrease has been attributed to the positive safety action of one major Australian airline.

Between January and June 2015, the operator reported only three fumes and smoke events to the ATSB. This represents a significant decrease from the operator’s five-year average of 16.8 occurrences per quarter.

The operator’s decrease in fumes and smoke events were likely the result of:

  • the retirement of older generation aircraft
  • a reduction in the number of flights
  • modifications of some engines
  • changes made to maintenance activities.

While all other airlines were consistent with their 5-year average, none of the 88 fumes and smoke occurrences were classified as high risk.

Systems issues, primarily relating to failure or malfunction of electrical and auxiliary power unit systems are the most common source of aircraft fumes and smoke. Equipment and furnishings (such as air conditioning and galley equipment) are also a common source.

Read the report Emerging trends in Australian aviation safety January – June 2015

Read an analysis of fumes and smoke events in Australia from 2008 to 2012

Light aeroplane engine failures

Over the 6-year study period between 2009 and 2014, 322 engine failures or malfunctions involving light aircraft were reported to the ATSB and/or Recreational Aviation Australia (RA-Aus).

Through routine trend monitoring of safety occurrence reporting, the ATSB became aware of a potential issue surrounding the frequency of light aircraft engine failures and malfunctions (both Australian VH and recreationally-registered). To formally and more fully examine the contributing factors behind these statistical observations, the ATSB initiated this Aviation Research investigation (under the provisions of the Transport Safety Investigation Act 2003).

Over the 6-year study period between 2009 and 2014, 322 engine failures or malfunctions involving light aircraft were reported to the Australian Transport Safety Bureau (ATSB) and/or Recreational Aviation Australia (RA-Aus). These reports involved single-engine piston aeroplanes up to 800 kg maximum take-off weight. Aircraft powered by Jabiru engines were involved in the most engine failures or malfunctions with 130 reported over the 6 years. This represents about one in ten aircraft powered by Jabiru engines in the study set having reported an engine failure or malfunction. Reports from Rotax powered aircraft were the next most common with 87 (one in 36), followed by aircraft with Lycoming (58 – one in 35) and Continental (28 – one in 35) engines. When factoring in the hours flown for each of these engine manufacturers, aircraft with Jabiru engines had more than double the rate of engine failure or malfunction than any other of the manufacturers in the study set with 3.21 failures per 10,000 hours flown.

Unlike the engines of other engine manufacturers in this study, nearly half of the Jabiru engine failures or malfunctions related to a fractured component. Engine through-bolt failures were the most commonly reported failure mechanism in Jabiru powered aircraft with 21 through-bolt fractures reported between 2009 and 2014. Taking into account the number of aircraft registered in the study period, through-bolt failures occurred in about one in 55 Jabiru powered aircraft. Although originally designed to be replaced after 1,000 hours, 19 through-bolts failed before the 1,000 hour mark, with seven failing before 500 hours. At least four failures involved engines with upgraded 3/8 inch diameter through-bolt nuts. There were no failures reported involving the newer 7/16 inch diameter through-bolts which are used in currently manufactured engines (present in about 20 per cent of Jabiru engines).

Jabiru Aircraft Pty Ltd have designed and tested a modified 3/8 inch diameter through-bolt which incorporates aspects to alleviate the effects of thermal expansion and damp resonant vibrations.

The ATSB has issued recommendations to Jabiru Aircraft Pty Ltd and the Civil Aviation Safety Authority to reduce the risk of engine failure or malfunction in aircraft fitted with Jabiru engines and to assure future reliability of these engines.

Safety message

Owners and operators of light aircraft with Jabiru engines that have 3/8 inch diameter through-bolt configurations need to be aware of the continued elevated risk of a through-bolt failure leading to an engine failure or malfunction in flight. It appears that Jabiru engine service bulletins, requiring upgraded through-bolts of the same thickness and upgraded nuts to the 12-side ARP nuts, may not have fully addressed this issue. Thicker 7/16 inch through-bolts (installed in newly manufactured engines and recommended as a retro-fit for aircraft conducting flight training), appear to have improved the reliability of Jabiru engines, although future monitoring will provide more definite evidence.

Read the ATSB research report AR-2013-107