Fume and smoke incidents in Australian aviation are usually appropriately managed by flight and cabin crew and generally result in minor safety consequences, according to a new report released today.

The report, jointly released by the Civil Aviation Safety Authority (CASA) and the ATSB, reveals that there were more than 1,000 fumes and smoke events reported over five years (between 2008 and 2012).

While the vast majority of these incidents were minor in nature, one event resulted in a single flight crew incapacitation and a further 11 events contributed to minor injuries to crew. In the higher risk occurrences, precautionary defences (most commonly diversions to nearby airports) were found to be effective in avoiding escalation of the event.

The report encourages aircraft operators to continue reporting fumes/smoke incidents to the ATSB and CASA to ensure the ongoing risks are effectively monitored.

The report shows that the most common source of fumes and smoke was a result of aircraft systems issues, primarily relating to failure or malfunction of electrical and auxiliary power unit systems. Equipment and furnishings also featured highly as a source of fumes and smoke. Within this category, air conditioning and galley equipment were the most common sources of fumes/smoke. External sources of fumes/smoke and cargo/baggage related events were relatively rare.

The British Aerospace BAe 146 was the aircraft type most commonly involved in fumes/smoke events when taking into account flying activity. The Embraer EMB-120 Brasilia, Fokker 100, and Bombardier DHC-8-100/200 series aircraft also had a higher than average rate of fumes/smoke occurrences over the period.

The ATSB and CASA conducted the study to further understand the nature and impact that fumes and smoke have on aviation safety. The report also addresses recommendations from a 2011 report from an expert panel on aircraft air quality that aviation safety agencies work together to provide a comprehensive study of cabin air contamination incidents.

The report encourages aircraft operators to continue reporting fumes/smoke incidents to the ATSB and CASA to ensure the ongoing risks are effectively monitored.

Read the full research report AR-2013-213

Victoria joins the national rail safety program.

From today, (19 May 2014) most Victorian rail operators will have new mandatory reporting regulations that change the way they report accidents and incidents. 

All Category A occurrences (serious incidents and accidents) will need to be reported immediately to the Australian Transport Safety Bureau (ATSB) by telephone on 1800 011 034.

This must be followed up within 72 hours by a written report to the Office of the National Rail Safety Regulator (ONRSR). In addition, all Category B occurrences will also need to be reported, in writing only, to the ONRSR within 72 hours.

The changes to reporting regulations are part of historic reforms to rail safety legislation that see Victoria’s railways having both a national rail safety regulator (ONRSR) and a national rail safety investigator (the ATSB).

All Category A occurrences (serious incidents and accidents) will need to be reported immediately to the Australian Transport Safety Bureau (ATSB) by telephone on 1800 011 034.

The scheme also allows any person to confidentially report a safety concern about a rail operation to the ATSB by calling 1800 011 034. 

The information the ATSB gets from mandatory and confidential reports helps determine whether we need to investigate a rail safety matter or alert the relevant people in the event of a safety concern. Ultimately, reporting can save lives and prevent injuries. 

More information:

• Category A report to the ATSB
• National safety investigation reforms

Australian Transport Safety Bureau (ATSB) is a proud Privacy Awareness Week partner. Privacy Awareness Week is held every year to promote awareness of privacy issues and the importance of the protection of personal information.

Privacy continues to be a hot issue for businesses, government agencies and of course you, our customers. We recognise that our customers value their privacy.  Research has shown that 60 per cent of Australians have decided not to deal with a private business and 25 per cent have decided not to deal with a government agency due to concerns as to how their personal information will be used.

New Australian privacy laws came into force on 12 March 2014. The changes include a new set of Australian Privacy Principles that regulate how we handle your personal information and new enforcement powers for the Office of the Australian Information Commissioner (or OAIC), the federal Australian Government body responsible for privacy in Australia.

These were the most significant changes to privacy laws in over 25 years, affecting a large section of the community.

One of the aims of the new privacy laws is to ensure that your personal information is managed in an open and transparent way.  We take your privacy very seriously, and we want you to know that we have updated our privacy policy in line with the new requirements.

You can access our privacy policy on our website at 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
• how you can make a privacy complaint us.

Of course, we are not the only agency that collects your personal information. Here are some tips 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, and if it is going to be given to another agency or organisation
• Only give out as much personal information as you need to — always think before handing your personal information over
• Ask for access to your personal information
• Make sure the information an organisation or agency holds about you is accurate and up to date
• Take steps to protect your online privacy
• Make sure your hard copy records are properly destroyed
• You can 'opt out' of marketing communications if you do not want to receive any further contact of this kind
• Make a privacy complaint if you consider that your personal information has not been handled properly.

The ATSB has just released a new aviation bulletin containing 10 investigation reports. The Aviation Short Investigation Bulletin Issue 29 covers short, office-based investigations.

The bulletin covers incidents, serious incidents and accidents involving piston aircraft, as well as helicopters.

Short investigations cover incidents and accidents where the associated factors are usually well-understood and do not require more detailed investigations. Nonetheless, each investigation has the potential to produce important Safety Messages for pilots, operators and others in the aviation industry. The investigations also help the ATSB identify statistics and trends in air safety.

Issue 29 of the Bulletin features 10 safety investigations:

Piston aircraft

• Loss of control during landing involving Cessna 182 VH-LMA
• Fuel starvation and forced landing, involving PA-31, VH-OFF
• Runway excursion involving a Beech A36, VH-EUB
• Inflight fire involving a Beech 58, VH-SBS

Helicopters

• Loss of control involving a Robinson R22, VH-HVW
• Ground fire involving a Robinson R44, VH-TZE
• Collision with terrain involving a Bell 206B, VH-BNG
• Fuel exhaustion event involving a Hughes 269C, VH-HAK
• Collision with terrain involving a Robinson R44, VH-UGR
• Hard landing involving a Bell 206B, VH-XJA

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 29

A new web page featuring de-identified confidential reports on aviation, maritime and rail safety concerns is now available on the ATSB website.

A new web page featuring de-identified confidential reports on aviation, maritime and rail safety concerns is now available on the ATSB website.

The ATSB’s confidential reporting scheme, REPCON, allows people with safety concerns to report them confidentially to the ATSB without fear of being identified. These confidential reports often contain valuable information that can help industry address unsafe procedures, practices or conditions.

Because many important safety concerns are reported to the ATSB through REPCON, it is vital that all of industry is aware of, and can learn from, the reported concerns. To enhance awareness of these safety issues, the ATSB will make this information available through the publication of de-identified confidential reports on its website.

The published information will include details about safety concerns, as well as responses and safety actions taken by relevant organisations or government agencies about the concern.

It’s important to remember that the information published on the new web page is de-identified to protect the identity of the reporter or any third-party individual. REPCON serves to collect information about safety concerns in the aviation, marine and rail industries, to help facilitate safety action and, ultimately, improve transport safety. REPCON is not used to apportion blame or liability—the underpinning legislation specifically precludes information in a report being used for disciplinary purposes. As well, REPCON reports are inadmissible in evidence in a court, except where a person has committed an offence under the Criminal Code (False or misleading information) in making the report.

If you have any questions about the new web page or REPCON in general, call the REPCON reporting line on 1800 020 505.

• Read de-identified REPCON reports

Aircraft flight recorders are an invaluable tool for investigators in identifying the factors behind an aircraft accident.

Recorders usually comprise two individual boxes: the Cockpit Voice Recorder (CVR) and the Flight Data Recorder (FDR).

Popularly known as ‘black boxes’, these flight recorders are in fact painted orange to help in their recovery following an accident.

Read more about aircraft flight recorders

The ATSB has just released a new aviation bulletin containing 11 investigation reports. The Aviation Short Investigation Bulletin Issue 27 covers short, office-based investigations.

The bulletin covers incidents, serious incidents and accidents involving turboprop and piston aircraft, as well as helicopters.

Short investigations cover incidents and accidents where the associated factors are usually well-understood and do not require more detailed investigations. Nonetheless, each investigation has the potential to produce important Safety Messages for pilots, operators and others in the aviation industry. The investigations also help the ATSB identify statistics and trends in air safety.

Issue 27 of the Bulletin features 11 safety investigations:

• Aircraft separation issue involving an Ayres S2R, VH-WBK and an unmanned aerial vehicle
• Ground proximity event between Dornier DO228, VH-VJN and a vehicle
• Loss of ground control involving Air Tractor AT-502B, VH-FLH
• Ground proximity event involving a Cessna 208, VH-LNI and a vehicle
• Total power loss involving a Piper PA-28 161, VH-CCQ
• Incorrect configuration involving Beech A36, VH-YEN
• Hard landing involving a Rolladen-Schneider Flugzeugbau LS7-WL, VH-XJJ
• Hard landing involving a Cessna U206G, VH-UFT
• Collision with terrain involving a Grumman G 164A, VH-CCF
• Aircraft proximity event between a Piper PA-34, VH-FOE and a Piper PA-39, VH-MAB
• Wirestrike involving a Robinson R44, VH-HJT

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 27

The ATSB has just released a new aviation bulletin containing 11 investigation reports. The Aviation Short Investigation Bulletin Issue 28 covers short, office-based investigations.

The bulletin covers incidents, serious incidents and accidents involving jet, turboprop and piston aircraft, as well as helicopters.

Short investigations cover incidents and accidents where the associated factors are usually well-understood and do not require more detailed investigations. Nonetheless, each investigation has the potential to produce important Safety Messages for pilots, operators and others in the aviation industry. The investigations also help the ATSB identify statistics and trends in air safety.

Issue 28 of the Bulletin features 11 safety investigations:

• Turbulence event involving a Boeing 777, VH-VPE
• Runway excursion involving a Fairchild SA226, VH-OGX
• Hard landing involving a Grob G 115C2, VH-ZIV
• Take off event involving a De Havilland DH-82 Tiger Moth, VH-RAY
• Loss of control involving a Piper PA-28R 201, VH-HVX
• Pilot incapacitation involving a Piper PA 28-180, VH-PXB
• Aircraft proximity event between a Cessna 172S, VH-FPV, and a Piper PA 28-161, VH-OWO
• Near collision between a Piper PA-25, VH-MLS, and an AMS-flight DG-303, VH-DGA
• Loss of separation between a Schweizer 269C, VH-HYD and a Piper PA-31, VH-IBI
• Engine failure involving a Eurocopter EC120B, VH-JYV
• Controlled flight into terrain involving a Robinson R22, VH-LZR

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 28

A weak track formation contributed to the derailment of six train wagons and damage to 15 km of track, according to a new ATSB report.

A weak track formation contributed to the derailment of six train wagons and damage to 15 km of track, according to a new ATSB report.

The derailment of the freight train 7SP5 occurred between Caragabal and Wirrinya, NSW on 23 October 2011.

At the time of the derailment, the train was travelling from Stockinbingal towards Parkes and was 14 hours into its journey from Sydney to Perth. The lead bogie (the undercarriage with wheels) of the 42nd wagon of the train derailed three kilometres north of Caragabal. The wheels of the bogie were dragged, off the rails, for about 15 km until they reached a turnout where six wagons separated from the train and overturned.

A dip in the track, combined with an adverse twist, caused the bogie to derail.

The ATSB found that a dip in the track, combined with an adverse twist, had caused the bogie to derail. Based on available evidence, it is likely that the track dip developed under train 7SP5 and was caused by an undetected weakness in the track formation. (The formation is the foundation of the track structure.) Track inspections had been conducted, but it is unlikely that the inspections would have identified any warning signs of formation weakness before the derailment.

Maintenance history indicated that track geometry defects had been identified and repaired around the site of the derailment, but they were generally not significant when compared to the defect that caused the derailment and defects identified and rectified in other locations along this track. Since this serious incident, the Australian Rail Track Corporation (ARTC) has implemented its Engineering Code of Practice for its rail network in NSW as part of an ongoing program of procedure standardisation across the ARTC rail network. The ATSB has urged managers and maintainers of track infrastructure to strengthen their predictive track maintenance systems by considering greater examination of historical maintenance and defect data.

Read the final report: Derailment of train 7SP5, between Caragabal and Wirrinya, New South Wales, on 23 October 2011

Over the recent summer months, the ATSB has seen an unprecedented increase in turbulence events.

The Australian Transport Safety Bureau’s monitoring of the latest aviation events has revealed a significant increase in the number of weather-related occurrences involving high-capacity air transport aircraft.

“We are seeing a doubling of turbulence and windshear events in passenger operations,” said Dr Stuart Godley, head of the ATSB’s Aviation Safety Research team. “And some of those events are affecting the safety of those in the cabin.”

The number of turbulence and windshear related occurrences involving high-capacity aircraft was significantly above the 5-year historical average.

Turbulence is caused by the irregular movement of air, and often cannot be seen. When air masses with different speeds, direction or temperatures meet each other, turbulence is likely to occur. While turbulence is normal and occurs frequently, it can be dangerous. 

The ATSB found that, from October to December of 2013, the number of turbulence and windshear related occurrences involving high-capacity aircraft was significantly above the 5-year historical average, and had actually doubled compared to the previous three months.

“Because they’re weather-related, these events are cyclical,” explained Dr Godley. “We’re used to seeing more of them in the summer, but this increase is unprecedented. We’re especially concerned because there is a correlation between these events and cabin safety issues, especially cabin injuries due to turbulence.”

In fact, turbulence is the leading cause of in-flight injuries to passengers and cabin crew. To help passengers understand turbulence and keep themselves safer, the ATSB has produced a booklet, Staying Safe against In-flight Turbulence, which is available for free download.