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

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(Opens in a new tab/window) welcoming the award.

Late afternoon glare and light refraction affected the pilot’s vision and depth of field, with tragic results.

Late afternoon glare and light refraction affected the pilot’s vision and depth of field, with tragic results.

On 28 May 2015, the pilot of a Robinson 22 helicopter, registered VH-HRW, was engaged in aerial mustering operations about 64 km north-north-east of Mitchell, Queensland. Late in the afternoon the helicopter’s tail rotor struck the branch of a 7 m‑high dead and defoliated tree, the pilot lost control of the helicopter and it collided with terrain. The helicopter was destroyed and the pilot, the sole occupant, was fatally injured.

The ATSB found that the pilot was appropriately qualified and flying due west in a serviceable helicopter at low level. The sun was to the north-west and about 13°–15° above the horizon at that time. The helicopter’s tail rotor collided with the upper branch of an isolated tree. That collision separated a portion of the tail rotor blades, leading to the remainder of the tail rotor and the helicopter’s horizontal and vertical stabilisers and tail rotor gearbox also separating. The pilot could not control the helicopter and it collided with terrain.

Given the conditions, it is likely that sun glare and the darkened backdrop of a tree-lined dry creek bed affected the pilot’s vision and perception, and therefore ability to identify the isolated tree. Despite the pilot wearing a helmet that was fitted with sun visors, the ATSB could not determine whether the visors were lowered at the time. In any event, it is likely that the pilot did not see the tree, or misjudged its height and/or its distance from the approaching helicopter.

The ATSB did not identify any pre-existing mechanical defects and established that, at the time of the accident, the helicopter was likely serviceable. The helicopter was fitted with a three‑point safety harness and bladder‑type fuel tanks. These tanks decrease the risk of a post‑impact, fuel‑fed fire. Despite these additional safety features, and the safety benefits possible from the pilot wearing a helmet, the accident was not survivable due to impact forces. A number of unrestrained items in the cabin increased the risk of injury as a result of those forces.

Safety message

Low-level aerial mustering operations are an inherently high-risk activity. When conducting this type of operation, pilots need to consider the environmental conditions as part of their flight planning and operational risk assessment. The ATSB and the Civil Aviation Safety Authority have released a number of publications illustrating the risks associated with this type of operation that provide guidance and strategies for mitigating those risks.

Read the final report: Collision with terrain involving Robinson R22, VH-HRW, 63 km north-north-east of Mitchell, Queensland, on 28 May 2015

A wasp nest obstructed the Captain’s pitot probe after a short layover in Brisbane

A wasp nest obstructed the Captain’s pitot probe after a short layover in Brisbane.

On 21 November 2013, after a flight from Singapore, an Etihad Airways Airbus A330, A6-EYJ landed at Brisbane airport and was taxied to the terminal. Approximately 2 hours later, the aircraft was pushed-back from the gate for the return flight to Singapore.

The captain rejected the initial take-off attempt after observing an airspeed indication failure on his display. The aircraft taxied back to the terminal where troubleshooting was carried out, before being released back into service.

During the second take-off roll, the crew became aware of an airspeed discrepancy after the V₁ decision speed and the take-off was continued. Once airborne, the crew declared a MAYDAY and decided to return to Brisbane where an overweight landing was carried out.

Engineering inspection after the overweight landing found that the Captain’s pitot probe was almost totally obstructed by an insect nest, consistent with mud-dauber wasp residue.

Engineering inspection after the overweight landing found that the Captain’s pitot probe was almost totally obstructed by an insect nest, consistent with mud-dauber wasp residue. The pitot obstruction had occurred during the 2 hour period that the aircraft was on the ground at Brisbane and was not detected during troubleshooting after the initial rejected take-off.

The aircraft operator has changed its policy on the use of pitot covers. They are now required to be used on all transits at Brisbane Airport, regardless of ground time.

The aircraft manufacturer has amended its maintenance troubleshooting manual to increase the likelihood that a blocked pitot probe will be detected.

The airport operator has extended its wasp inspection and eradication program and reviewed and updated its Wildlife Hazard Management Plan.

In addition, CASA has drawn attention to the safety implications of mud wasp activity through several publications.

Safety message

Operators can minimise the risk of pitot probe obstruction by consistently using pitot covers even during short transit periods.

Standard operating procedures include the cross-checking of airspeed during the take-off roll. These checks are an important last line of defence in preventing an aircraft from becoming airborne with airspeed indication problems.

Read the final report: Air data system failure involving Airbus A330-243, A6-EYJ, near Brisbane Airport, Queensland, on 21 November 2013

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.

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.

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.

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

Two large ships’ sterns broke away from their berths when a common bollard holding their stern lines failed, damaging a rail bridge and a third vessel.

Two large ships’ sterns broke away from their berths when a common bollard holding their stern lines failed, damaging a rail bridge and a third vessel.

On 17 August 2014, Grand Pioneer (Figure 1) and AAL Fremantle (Figure 2) broke away from their berths when a thunderstorm passed across the Port of Fremantle. A bollard on the wharf holding both ships’ stern lines failed, most likely after Grand Pioneer’s vehicle ramp contacted it. AAL Fremantle contacted a ship at an adjacent berth, and parts of the Fremantle Rail Bridge nearby.

The ships were berthed again with tug assistance. The ships had suffered minor damage. The rail bridge, however, was closed for 3 weeks for inspection and repairs to track alignment and other non-structural damage.

Figure 1: Grand Pioneer

Source: Marcus, Shipspotting

Figure 2: AAL Fremantle

Source: Australian Transport Safety Bureau

The ATSB investigation concluded that Grand Pioneer moved off the berth slightly as the tension in its mooring lines increased, in response to the high winds associated with the passing thunderstorm. It is likely that its vehicle ramp then made contact with the bollard that held the stern lines of both ships. As a result of the contact, the bollard broke away from the wharf.

The investigation found that Fremantle Port Authority’s (Fremantle Ports) examination of the risks associated with a ship contacting the rail bridge contained limited analysis on keeping ships alongside in adverse weather, particularly at berths 11 and 12 where the wind is predominantly on ships’ beams. There was also no analysis of the means to assist a ship that got close to Wongara Shoal and the rail bridge.

The ATSB also found that Fremantle Ports’ adverse weather procedures were triggered only by specific Bureau of Meteorology (BoM) forecast categories and terms. There was no guidance for vessel traffic service (VTS) officers to take action based on actual weather conditions, or other weather terms used in BoM forecasts.

Another investigation finding was that BoM’s marine forecast at the time of the incident did not describe expected wind speeds using recognised marine terms, such as ‘gale force’. Further, the forecast title understated the wind speeds expected.  

Fremantle Ports has put into service 12 ShoreTension devices in the inner harbour. These devices maintain a constant tension in a mooring line to assist keeping a ship alongside its berth.

The port has subscribed to a customized weather prediction service for its area, and upgraded its weather station and VTS equipment to enhance monitoring. The VTS officers have been trained to use the new and upgraded equipment. The port has updated its ship weather warnings to include a broader range of meteorological terms and descriptions.

Fremantle Ports has also revised its weather warning distribution list to include the manager of the rail bridge, the Public Transport Authority (PTA). The port and the PTA have established direct, high level, points of contact with communication processes in place to manage any emergencies that could involve the rail bridge.

The BoM safety action includes undertaking to use standard terminology in marine forecasts and implementing a formal process to consult stakeholders to better identify and meet their needs.

Safety message

When analysing the risks to a port’s operation, its operator needs to consider the risk controls to avoid a serious incident as well as the recovery controls in case an incident does occur.

Read the final report: Breakaway of Grand Pioneer and AAL Fremantle, at Fremantle, Western Australia, on 17 August 2014

Metal fatigue caused a welded boss on the No.2 engine to give way, resulting in a fuel-fed fire that was brought under control by the flight crew.

Metal fatigue caused a welded boss on the No.2 engine to give way, resulting in a fuel-fed fire that was brought under control by the flight crew.

On 29 April 2014 an AVRO 146-RJ100 aircraft, registered VH‑NJI and operated by Cobham Aviation Services Australia (Cobham), was on a charter flight to Barrow Island Airport from Perth Airport, Western Australia. The aircraft sustained a mechanical failure of the No. 2 engine shortly after take-off that resulted in an in-flight fuel-fed engine fire.

The flight crew extinguished the engine fire by shutting down the No. 2 engine and activating the fire suppression system. The aircraft was flown back to Perth Airport, having sustained significant damage to the No. 2 engine and cowling. There were no injuries.

The Honeywell International Inc (Honeywell) LF507-1F (LF507) engine has four combustion liner locating pin welded bosses (welded boss) in the combustor turbine module (CTM) combustor housing (housing). The ATSB found that the welded boss located at the 2 o’clock position had cracked and fractured adjacent to the weld as a result of fatigue. The boss separated from the housing, allowing high-pressure combusting fuel to escape radially through the CTM housing, burning through the engine cowling.

The ATSB found that the normal scheduled visual inspection of the housing, which was designed to find cracks before they developed into a fracture, was ineffective in this case.

The ATSB also found that localised grinding of the inner and outer surfaces of the CTM housing, adjacent to the welded boss, had reduced its wall thickness from 0.050 to 0.035 inches. The reduced wall thickness increased local stresses and hence the likelihood of crack formation. The crack accelerated at an unpredictable rate until penetrating the full thickness of the housing. It is likely that the grinding was associated with a weld repair conducted during a CTM heavy maintenance visit. The grinding repair was not an acceptable repair to Honeywell for returning the component to the original design strength.

Finally, the ATSB found that the normal scheduled visual inspection of the housing, which was designed to find cracks before they developed into a fracture, was ineffective in this case. This was because the reduced wall thickness invalidated the original crack growth rate predictions.

In response to this occurrence Cobham proactively inspected all of their LF507 engines, focusing on the welded bosses. Of those engines, one spare engine had grinding at one of the welded bosses, similar to the occurrence engine, and was withdrawn from the availability pool. Although no cracking was found at the combustion liner location pin welded bosses, Cobham did find seven cracks at the location of the ignition bosses that had not been previously identified. These cracks were managed in accordance with the Honeywell maintenance manual.

Honeywell also instigated several actions in response to this occurrence. These included amendment of the LF507 engine maintenance and overhaul manuals to address crack limits and weld repair specifications, and the issue of a Service Bulletin to alert operators of possible welded boss cracking.

Safety message

This occurrence highlights the importance of repairing aircraft components in accordance with the manufacturer’s specifications and ensuring that the repair meets the design intent of the manufacturer.

Read the final report: In-flight engine fire involving AVRO 146-RJ100, VH-NJI, departing Perth Airport, Western Australia, on 29 April 2014

A collision between a ute and aircraft shows why good communications is essential in all aircraft operations.

• A collision between a ute and aircraft shows why good communications is essential in all aircraft operations.

On 17 September 2015, the pilot of an Air Tractor 502B aircraft, was conducting aerial application (spraying) operations on a property about 23 km to the west of Hay Aerodrome, New South Wales.

As per normal procedure, while en route to the spray application area, the pilot made a broadcast on UHF Channel 25 advising that spraying operations were about to commence, and also, the area where that would occur. UHF Channel 25 was monitored by employees on the property, and used for general communications.

The driver of a tractor operating in the southern part of the spray application area responded to the pilot’s broadcast. The pilot advised the tractor driver that they would be able to safely continue in that southern area for about another hour.

After a short time, the pilot departed the spray application area and reloaded the aircraft with more chemical mixture at a nearby property. The pilot then returned to the spray allocation area at about 1130. This time, the pilot did not make another UHF broadcast, but noted that the tractor was now in transit between work areas, with a Toyota Hilux Double-Cab utility vehicle following closely behind.

At about 1145 as the pilot was conducting a spray run to the east, the pilot reported seeing the Hilux turn onto an irrigation channel crossing ahead of the aircraft. However as the vehicle appeared to be slowing to a stop short of the intersection, the pilot assumed the Hilux driver had seen the aircraft, so continued with the spray run. After checking the spray nozzles on the wings, and the spray pressure gauge, the pilot initiated a short climb to clear the raised channel bank.

The pilot then sighted the Hilux on the highest part of the channel bank. The pilot immediately ceased the spray and initiated a steeper climb. During this attempt, the left wheel of the aircraft struck the tray headboard of the Hilux from behind.

The pilot radioed for assistance for the driver and flew to a nearby property to land.

As a result of this occurrence, the agricultural company have revised some procedures, roles and responsibilities.

This accident highlights the importance of effective communication by all parties involved with aircraft operations.

ATSB Research and Analysis Report AR-2015-031 Aerial application safety: 2014 to 2015 year in review, provides statistical data regarding aerial application accident rates, and summarises a number of accidents that occurred during aerial application operations.

Read the final report: Collision with a vehicle involving an Air Tractor AT-502B, VH-FNX, near Hay, New South Wales, on 17 September 2015

This shipboard fire quickly got out of control causing extensive damage and several injuries due to smoke inhalation. An open cabin door and a stairwell fire door left hooked open were contributing factors.

This shipboard fire quickly got out of control causing extensive damage and several injuries due to smoke inhalation. An open cabin door and a stairwell fire door left hooked open were contributing factors.

On the morning of 9 October 2014, a fire started in Ocean Drover’s crew accommodation while the livestock carrier was berthed in Fremantle, Western Australia. The fire quickly spread across both accommodation decks. The ship’s crew and shore emergency response teams responded, and fire-fighting efforts continued for the rest of the day.

By the time the fire was extinguished late that evening, the ship’s accommodation areas and its navigation bridge had been extensively damaged. Four of the ship’s crew sustained injuries that required medical treatment.

The ATSB found that the fire started in a centrally located forward cabin on Ocean Drover’s upper deck. The intensity of the fire and the severity of the damage made it impossible to identify an exact point of origin or source of the fire.

The ATSB investigation found that the cabin door was left open after the fire was discovered allowing smoke and flame to spread beyond the cabin. Further, the bridge deck stairwell fire door was hooked open, which allowed the fire to rapidly spread and engulf both the upper and bridge decks.

The investigation also identified that the ship’s crew did not complete a muster and accurate head count when responding to the fire.

While cigarette smoking was not identified as a contributing factor, it was found that the smoking policy and associated risk controls on board were not effectively managed.

Ocean Drover underwent extensive post-fire repairs before it could return to service. During the repair period, the ship’s managers took pro-active safety action to avoid a similar incident in the future. All cabins in the ship’s accommodation were fitted with smoke detectors. The bridge deck stairwell fire door was replaced with one that is not fitted with a hold back arrangement (to comply with mandatory regulations). Notices posted on both sides of the door require it to be kept closed.

The ship’s managers have revised the shipboard smoking policy and restricted smoking to designated rooms, which exclude crew cabins. Designated smoking rooms are provided with safety ashtrays and sand bins, and warning signs have been posted in accommodation areas. The managers promulgated the lessons learned from the fire and safety action taken across the fleet through procedural changes and safety meetings.

Safety message

Containing a shipboard fire in the compartment where it originates is critical to firefighting.

Effective containment relies on maintaining the integrity of fire divisions, including bulkheads, decks and doors. In this regard, particular attention must be paid to ensuring fire doors, designed to limit or prevent the spread of fire, are never latched/lashed open, or otherwise compromised.

Read the final report: Fire on board the livestock carrier Ocean Drover, Fremantle, Western Australia, on 9 October 2014