Research report focusses on occurrences over the last ten years, identifying improvements and problems.
The ATSB’s latest research report focusses on aviation safety occurrences over the last ten years, identifying improvements and problems.
Every year, thousands of safety occurrences involving Australian-registered and foreign aircraft are reported to the ATSB by individuals and organisations in Australia’s aviation industry, and by the public. The vast majority are minor, but there are serious incidents and accidents. Each notification is retained in the ATSB’s databases, building up a detailed picture of Australian aviation.
The report describes what accidents and incidents have happened, how often they are happening, and what we can learn from them.
The new ATSB report, Aviation Occurrence Statistics 2003 to 2012, gives that information back to pilots, operators, regulators, and other aviation industry participants. The report describes what accidents and incidents have happened, how often they are happening, and what we can learn from them.
In 2012, there were 107 accidents, 195 serious incidents, and over 7,300 incidents reported to the ATSB involving Australian (VH– registered) aircraft, and a further 570 occurrences that involved foreign-registered aircraft operating within Australia or its airspace. A new addition to this report is data on 274 occurrences involving recreational (non–VH) aircraft safety.
These statistics provide an important reminder to everyone involved in the operation of aircraft that accidents, incidents, and injuries happen more often than is widely believed. Some of the most frequent accident types are preventable, particularly in general aviation.
A research report released today by the ATSB reveals that the vast majority of loss of aircraft separation occurrences in Australia present little or no risk of collision, but more can be done to improve safety.
A research report released today by the ATSB reveals that the vast majority of loss of aircraft separation occurrences in Australia present little or no risk of collision, but more can be done to improve safety. (A loss of separation occurs when two aircraft under air traffic control come closer than a minimum separation distance.)
The report shows that Australia has one of the lowest loss-of-separation occurrence rates, attributable to civilian air traffic control, in the world. A loss of separation (LOS) between aircraft under air traffic control happens on average once every 3 days. In almost 90 per cent of LOS occurrences there was no or a low risk of aircraft colliding. Australia has about six LOS occurrences each year that represent an elevated safety risk. However, a LOS does not normally indicate that there was a near-collision between aircraft. There have been no midair collisions in Australia involving aircraft being provided with a separation service by air traffic control.
The report also reveals that half of all LOS occurrences are attributable to air traffic controller actions, while the other half result from pilot actions. The ATSB considers that more can be done to learn from LOS occurrences attributable to pilot actions in civil airspace.
The number of LOS occurrences under military control was found to be relatively high and most are the result of controller actions. The report finds that current regulatory arrangements do not enable the Civil Aviation Safety Authority (CASA) to give the same level of safety assurance for civilian aircraft under military control as it does for aircraft under civilian control. The ATSB has issued safety recommendations to the Department of Defence and CASA to address the safety issues identified in the report.
The release of this report coincides with the release of two other ATSB investigation reports into separate incidents (one near Ceduna, SA and the other about 900 km northwest of Karratha, WA) that involved losses of separation between passenger aircraft under air traffic control. As part of the Karratha investigation, the ATSB issued two safety recommendations to Airservices Australia. These recommendations were issued in response to the limited formal guidance available on the monitoring of newly endorsed controllers and the use of clearances that allow aircraft to operate anywhere between two flight levels, rather than at a single level.
All three reports are available on the ATSB website.
AR-2012-034 Breakdown of separation between aircraft in Australia: 2008 to 2011
AO-2011-144 Breakdown of separation - Boeing 737, VH-VXM and Boeing 737, VH-VUV, near Ceduna Airport, SA, 8 November 2011
AO-2012-012 Loss of separation between Airbus A320, 9V-TAZ and Airbus A340, A6-EHH near TANEM, 907 km NW of Karratha, WA, 18 January 2012
A helicopter accident at Horn Island has shown the challenges that can accompany night operations, as well as the speed with which things can suddenly go wrong.
A helicopter accident at Horn Island has shown the challenges that can accompany night operations, as well as the speed with which things can suddenly go wrong.
The accident occurred on 13 June 2013. At about 7.24 pm, a Bell 412 helicopter departed Horn Island, Queensland on a training flight to Prince of Wales Island in the Torres Strait. It was a dark night with a small crescent moon and no discernible horizon. On board was the pilot flying (PF) who was under instruction, a training pilot, and a crewman. The purpose of the flight was to conduct several practice approaches using a searchlight to illuminate the ground. Each approach would be conducted to about treetop height, from where a go-around was to be commenced. The manoeuvres were demanding, and would require a high degree of precise flying.
Earlier in the day, the crew had positioned a strobe light at the target location, so that it would be visible on the night flight.
Having returned to the location for the training, they set about conducting their first practice approach, flying towards the strobe as they descended from 2,000 ft.
At 1,000 ft above the ground, the crewman opened and secured the cabin door. Due to the wind rush he did not look outside continuously until reaching about 400 ft, after which time he was to provide instructions to guide the pilot to the landing area once the PF lost sight of the strobe beneath the helicopter.
Due to the wind rush he did not look outside continuously until reaching about 400 ft, after which time he was to provide instructions to guide the pilot to the landing area once the PF lost sight of the strobe beneath the helicopter.
As they drew nearer to the strobe, the training pilot looked out of the cockpit to confirm all was well to continue a visual approach. When he looked back, he saw that they were descending at a high rate and that the airspeed was below 35 knots. He called ‘Go around’. As there was no immediate response, he repeated the call to go around.
Although the PF commenced a go-around and responded ‘Going around,’ the crewman observed that the helicopter was still descending rapidly and approaching the trees. He called ‘Climb, climb, climb.’ Despite the actions of the pilot, the descent continued and he again called ‘We are going backwards, trees, climb, climb, climb!’
The training pilot took the controls to assist with the go-around and then became aware of the trees in his peripheral vision. As the helicopter descended into the trees, he called ‘Brace, brace, brace!’
The helicopter hit the ground heavily and remained upright.
The crew were uninjured, but the helicopter was substantially damaged. They shut down the helicopter and discharged flares from the accident site, to assist rescuers in locating them.
The helicopter operator hypothesised that the high rate of descent and decreasing airspeed resulted in a vortex ring state—an aerodynamic condition in which the helicopter’s own downwash recirculates, with a potential loss of control.
As a result of this accident, the helicopter operator is conducting a management review into a Flight Safety Instruction that will prohibit unaided (non-night vision goggles) remote landings at night.
The ATSB has just released a new aviation bulletin containing 11 investigation reports. The Aviation Short Investigation Bulletin Issue 22 covers short, office-based investigations.
The bulletin covers incidents, serious incidents and accidents involving turboprop aircraft, piston aircraft and helicopters. No one was injured in any of the incidents; however, some of the aircraft suffered substantial damage.
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.
A new ATSB video shows how easily unexpected events can dramatically increase confusion among flight crew while landing the aircraft.
The incident featured in the video is just one in an increasing number of cases where pilots mishandle or mismanage their aircraft when something unexpected happens during the approach to land phase.
ATSB Chief Commissioner, Martin Dolan, said flight crew and operators should be aware of the growing number of safety occurrences, worldwide, during the landing phase.
“When compared to other phases of flight, the approach and landing has a substantially increased workload and risk,” Mr Dolan said.
“The ATSB has investigated several incidents that occurred during the approach to land and found that poor communication and lack of role clarification were worryingly common.
“As well as showing how easily flight crew can become confused during an unexpected event, the video emphasises the importance of conducting a go-around to ensure a safe outcome.”
The ATSB’s SafetyWatch initiative provides more information on handling the approach to land along with links to related ATSB investigations.
The video features the accident of a crew member on board a ship who was tragically killed by an explosion while cutting a used 200 litre drum with an angle grinder.
A new video highlighting the ongoing safety concerns for maritime workers has been released by the ATSB today.
The video features the accident of a crew member on board a ship who was tragically killed by an explosion while cutting a used 200 litre drum with an angle grinder.
ATSB Chief Commissioner, Martin Dolan, said the ATSB has investigated several accidents involving unsafe work practices in the maritime industry.
“We continue to investigate maritime accidents that result in serious injury or death following falls from height, crushing and exploding equipment,” Mr Dolan said.
“These accidents could’ve been avoided if the workers had just given some time to think about the risks involved before they started the task.
“The video provides a powerful reminder to all workers of the need to take risk seriously and to make sure the risk is appropriately managed.”
You can find more information about unsafe marine work practices, along with the ATSB’s other top transport safety priorities, on the SafetyWatch web page.
The ATSB today released a new YouTube video that demonstrates the serious consequences of simple, undetected human error in data calculation and entry.
The ATSB today released a new YouTube video that demonstrates the serious consequences of simple, undetected human error in data calculation and entry.
The video features animation from the 2009 tail strike accident of an Airbus A340 at Melbourne Airport. In that accident, the crew inadvertently entered the take-off weight data into the aircraft’s electronic flight bag to calculate the aircraft’s take-off settings. The error passed through several subsequent checks without detection.
Through its SafetyWatch initiative, the ATSB has identified data input error as a top safety priority requiring heightened attention from the aviation industry.
While no one is immune from data input errors, risk can be significantly reduced through effective management and systems.
While no one is immune from data input errors, risk can be significantly reduced through effective management and systems. Good communication and independent cross-checks between pilots, effective operating procedures, improved aircraft automation systems and software design, and clear and complete flight documentation will all help prevent or uncover data entry errors.
The ATSB has completed its safety review of the interstate rail line between Melbourne and Sydney, identifying underlying issues and evaluating the response of the operator.
The ATSB has completed its safety review of the interstate rail line between Melbourne and Sydney, identifying underlying issues and evaluating the response of the operator.
In 2007, the Australian Rail Track Corporation (ARTC) embarked on a major investment program to upgrade the rail track between Melbourne and Sydney. Since the program began, there have been a number of incidents and the condition of the line has attracted adverse comment regarding its safety, mostly in relation to rough rides and the development of mud-holes.
On 16 August 2011, the Hon Anthony Albanese MP, Minister for Infrastructure and Transport, requested that the ATSB undertake an investigation to examine the safety of the line’s operations.
While the treatments applied to date are likely to correct most ballast and drainage problems, the treatments are unlikely to correct the more deep-seated formation problems.
Among various issues, the ATSB investigation found that the track structure between Melbourne and Sydney had historically been particularly vulnerable to degradation in vertical alignment, resulting in the mud-holes and poor ride quality. While this was the result of a number of factors, major contributors were ballast fouling (contamination of the aggregate material laid between the formation and the rails and sleepers) and the weakness of the track formation (the earthwork foundation on which the track was laid).
In some locations, the track upgrade has increased this pre-existing vulnerability as a result of the process of installing new concrete sleepers.
The track deterioration following the re-sleepering works has required both short-term management and the development of a longer-term major rectification program to maintain the operational effectiveness of the track. Until that rectification takes place, the safety of train operations has been maintained largely through the application of speed restrictions. These speed restrictions, together with increased maintenance activities, have resulted in extended train running times along the corridor.
While the treatments applied to date are likely to correct most ballast and drainage problems, the treatments are unlikely to correct the more deep-seated formation problems. Unless additional treatments are applied to improve the formation, it is possible that water will continue to weaken the structure in some locations. That would, in turn, require an increased regime of track maintenance (or some localised formation reconstruction) and the application of new or further speed restrictions.
The ATSB is satisfied that, taken as a whole, the necessary steps have been taken to address any issues that might otherwise compromise the safety of rail operations on the Melbourne to Sydney line where track quality is below acceptable operational standards. However, the actions taken to ensure safe operations have come at the expense of operational efficiencies through increased train running times.
The ATSB is supporting Rail Safety Week, which is being held from 12 to 18 August 2013.
The Australian Transport Safety Bureau is supporting Rail Safety Week, which is being held from 12 to 18 August 2013. In its eighth year, Rail Safety Week is an initiative of the Australasian Rail Industry and aims to raise awareness of safety issues around railway lines.
During the week, the ATSB will highlight the ongoing concerns of safe work on rail. We’ve investigated several accidents that have occurred when maintenance work was being carried out on or near railway tracks. Through our SafetyWatch initiative, we urge industry to give heightened attention to the risks and hazards facing rail workers.
ATSB report into a collision between two road rail vehicles that left one driver trapped and seriously injured while five other people sustained minor injuries.
The Australian Transport Safety Bureau (ATSB) has released its preliminary investigation report into a collision between two road rail vehicles that left one driver trapped and seriously injured while five other people sustained minor injuries.
The accident occurred on 4 June 2013, on the West Coast Wilderness Railway in Tasmania. The road rail vehicles used on the railway are trucks designed to travel on both the road and on train tracks. When they transition from the road, they use front and rear sets of rail guidance wheels, which are lowered when the vehicle is positioned on the track. On the day of the accident the track workers placed the road rail vehicle on the track and were preparing to travel to a worksite near Rinadeena Station when it unexpectedly started to roll backwards. The driver was unable to slow the vehicle, so he and the passenger jumped clear, suffering minor injuries.
The vehicle continued to accelerate, out of control, down the steep slope, heading towards a second road rail vehicle containing four track workers.
The now-unmanned vehicle continued to accelerate, out of control, down the steep slope, heading towards a second road rail vehicle containing four track workers. Two passengers of the second vehicle jumped clear, sustaining minor injuries, but a third passenger and the driver were still inside when the unmanned road rail vehicle collided with theirs, pushing it back about 40 m along the track. The passenger sustained minor injuries, but the driver was trapped and seriously injured in the collision. He was subsequently removed from the vehicle and air lifted to hospital. Both road rail vehicles were extensively damaged.
The preliminary ATSB investigation has found that the first vehicle’s rear road-going tyres were lifted from the track during an inspection of the rear rail guidance wheels. As a result, the braking force provided by them was lost and the vehicle began to roll down the grade. The investigation has also found that West Coast Wilderness Railway had not considered all of the risks associated with operating road rail vehicles on the steep railway and, therefore, had not identified the need for operator specific procedures and training.
While the investigation is ongoing, the ATSB is encouraging all rail organisations that operate road rail equipment to consider the advice in safety alert RISN Number 7/2012 Risk associated with Hirail Operations (issued by the Department of Infrastructure, Energy & Resources, Tasmania).
