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.

More videos available on our YouTube channel(Opens in a new tab/window)

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.”

Effective simulator training and robust failure management procedures proved invaluable to the passengers and crew of an early-morning Regional Express flight from Ballina, NSW, on 23 August 2016.

The SAAB 340 aircraft, comprising three crew and 22 passengers, suffered an engine failure shortly after take-off.

As the landing gear was retracting, the crew heard loud bangs and the left engine operation degraded, reducing the climb performance. Passengers alerted crew to flames coming from the affected engine.

Based on noises and engine instrument indications, the crew identified the issue as a compressor stall, and carried out the failure management procedure. The left engine was shut down and the first officer advised ATC that they had one engine inoperative.

The flight returned safely to Ballina, with no injuries to crew or passengers and no damage to the aircraft.

The two members of the flight crew said their simulator training, dealing with compressor stalls and one-engine-inoperative scenarios, had helped manage the situation. The captain also said the aircraft was easier to handle than the simulator.

Faced with an abnormal scenario, thanks to their training and robust procedures, the crew was able to manage a challenging situation efficiently and safely.

Read the final report: In-flight engine shutdown involving Saab 340, VH-ZRJ, 19 km north of Ballina/Byron Gateway Airport, New South Wales, on 23 August 2016

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