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.

Papua New Guinea continues to strengthen aviation safety with 12 Papua New Guineans completing training to international standards in air accident reporting.

Papua New Guinea continues to strengthen aviation safety with 12 Papua New Guineans completing training to international standards in air accident reporting.

The training course, jointly run by the PNG Accident Investigation Commission (AIC) and the ATSB, covered the preparation of aviation accident and serious incident reports that meet international standards. The ATSB has been working closely with the PNG AIC to conduct a series of training courses for PNG citizens working in the aviation industry.

The Australian Government shares a partnership goal with PNG of improving aviation services to comply with international safety and security services. The 12 PNG aviation professionals from the public sector and from private aviation operators undertook a five-day course in air accident reporting that began on 10 February at the Air Nuigini Training Centre at Jackson’s Airport, Port Moresby.

Through the PNG Australia Transport Sector Support Program, Australia assists PNG to improve aviation through a diverse range of initiatives.

Conducted by a former ATSB Director, Alan Stray, the course explained International Civil Aviation Organization (ICAO) requirements for accident and serious incident reporting. Through a series of practical examples, participants built their knowledge and skills to prepare accident and incident reports that meet international standards and support improvements in aviation safety in PNG.

The participants, including three women, worked hard and saw the challenging course as a boost to their career prospects. Ms Bessie Andrew of PNG Air Services said, ‘I was so pleased to see other women participants. Accident report writing requires attention to detail and well-developed analytical skills. I feel that this is a great career opportunity for women in PNG.

The Minister for Civil Aviation, the Hon Mr Davis Stephen recognised the training to ICAO standards and presented certificates in a ceremony on 14 February 2014.

Future training courses will cover Safety at Accident Sites and Aircraft Accident Investigation Fundamentals. 

Through the PNG Australia Transport Sector Support Program, Australia assists PNG to improve aviation through a diverse range of initiatives.

Course participants included public sector and private aviation operators

 Ms Jean Mose, manager quality and safety at Airlines PNG, receives her certificate of completion from Civil Aviation Minister Steven Davies

The ATSB has just released a new aviation bulletin containing 9 investigation reports. The Aviation Short Investigation Bulletin Issue 26 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 26 of the Bulletin features 9 safety investigations:

• Loss of separation assurance between an Airbus A320, VH-VNQ and Boeing 737, VH-VZB
• Incorrect configuration involving Airbus A320, VH-FNP
• Flight planning related event involving an Airbus A330, VH-QPD
• Turbulence event involving a Boeing 767, VH-OGU
• Fuel related event involving a Fairchild SA227, VH-UUO
• Electrical system event involving a Cirrus SR22T, VH-LBQ
• Aircraft proximity event between a Piper PA-44, VH-CZH and a Mooney M20, VH-DJU
• Loss of control involving a Eurocopter EC-120B, VH-VMT
• Aircraft proximity event between a Bell 206, VH-WCS and a PZL Bielsko 51, VH-XOP

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 26

Rail operators are being reminded of the need to report Category A rail occurrences to the Australian Transport Safety Bureau (ATSB) following a number of incidents that have not been reported as required.

Recent reforms to national rail safety legislation have resulted in changes to the way rail occurrences need to be reported in some states and territories. By law, rail transport operators in South Australia, Northern Territory, Tasmania and New South Wales must now verbally report Category A incidents to the ATSB.

A review of reports received by the ATSB, and the Office of the National Rail Safety Regulator (ONRSR) has shown inconsistencies in reporting patterns. In particular:

• some Category A notifiable occurrences are being reported in written form to the ONRSR only with no verbal report to the ATSB
• some Category A notifiable occurrences have been incorrectly classified by operators as Category B and only reported to the ONRSR.

The ATSB and ONRSR remind all operators in these states and the Northern Territory of their responsibilities under the law and that failing to report category A occurrences to the ATSB may incur a penalty. 

All Rail Safety National Law (RNSL) occurrences resulting in serious injury are classified 
Category A 
and only those accidents that result in hospital admission should be reported.

The ONRSR also reminds operators that under the rail national safety law, a running line derailment is a Category A occurrence. (A number of such occurrences have not been reported to the ATSB.)

All Rail Safety National Law (RNSL) occurrences resulting in serious injury are classified Category A and only those accidents that result in hospital admission should be reported (against this category).

The ATSB and ONRSR have released a fact sheet to help operators better understand their reporting responsibilities.

• Fact sheet: Reporting Cat A rail occurrences to the ATSB