A new booklet released by the ATSB today dispels the myth that experience will always protect pilots from an accident.

A new booklet released by the ATSB today dispels the myth that experience will always protect pilots from an accident.  

The booklet Experience won’t always save you: Pilot experience is not always a protection against an accident, is the latest release in the ATSB’s well-received Avoidable Accidents series.  

“There’s a reverence for those who have been flying a long time,” said Dr Stuart Godley, the manager of the ATSB’s Research Investigations and Data Analysis. “We like to believe that they’ve got the right stuff, that they know themselves and their aircraft, and they can draw on their wisdom to keep themselves safe. There are many famous accidents where it appears that pilot experience has made all the difference.”

These were experienced pilots
who knew their business, but it wasn’t enough to keep them safe.

 “However, a closer analysis of these accidents suggests that things other than experience alone have always also played a significant part in saving the day,” continued Dr Godley, “but they tend not to be emphasised in anecdotes and media.”

“On the other hand, fatal outcomes can and do happen to very experienced pilots, leading to questions of how could such a thing happen to someone with so much flying behind them.”

In creating this booklet, the ATSB has drawn on its investigation archives of 20 years to find case studies that illustrate how a fatal accident can happen to anyone, even those who have been flying for years. These examples cover a range of operations and aircraft types, and each one analyses the accident, breaking down the decisions and factors that contributed to the final, fatal result. 

“These were experienced pilots who knew their business,” said Dr Godley, “but it wasn’t enough to keep them safe.”

In some of these occurrences, very experienced pilots were undertaking flying that involved much higher risk. It turned out that their flying experience alone was unable to help them avoid disaster. Other accidents involved experienced pilots who may have allowed factors other than their experience to influence their actions. In other examples, the pilot’s vast experience may have even led to decisions that, in hindsight, were associated with more risk than necessary.

As with all the Avoidable Accidents booklets, Experience won’t always save you is available for free. “The book can be downloaded from the ATSB website or we’re happy to mail free copies to anyone who would like them,” said Dr Godley. “We’ve had excellent feedback on these publications—they’re a useful resource to anyone involved in flying, but we feel that this newest booklet is especially important. The issues that it examines are something that all pilots need to think about and take into account.”

Please send requests for copies of the booklet via email to atsbinfo@atsb.gov.au 

The ATSB has released a new aviation bulletin featuring nine investigation reports. The Aviation Short Investigation Bulletin Issue 15 presents short, office-based investigations conducted over the past nine months.

The Australian Transport Safety Bureau has released a new aviation bulletin featuring nine investigation reports. The Aviation Short Investigation Bulletin Issue 15 presents short, office-based investigations conducted over the past nine months. 

The bulletin covers incidents and accidents involving turboprop piston aircraft, and helicopters. None of the accidents were fatal; however, some of the aircraft sustained 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.

The incidents covered in the report include:

• Aircraft proximity event between Beech 1900, VH-EMK and Airparts FU-24, VH-HVP  (AO-2012-134)
• Weather balloon event involving Bombardier DHC-8-400, VH-LQG (AO-2012-144)
• Runway excursion involving Piper PA-39, VH-MMN (AO-2012-145)
• Wheels up landing involving Beech A36, VH-SQI (AO-2012-151)
• Landing on a closed airstrip involving a Piper PA-28R, VH-HKZ (AO-2012-155)
• Ditching involving Robinson R44, VH-CYH (AO-2012-096)
• Power loss involving Robinson R44, VH-NWD (AO-2012-136)
• Hard landing involving Cabri G2 VH-CDU (AO-2012-140)
• Controlled flight into water involving Robinson R22, VH-HOA (AO-2012-146)

Read the ATSB’s Aviation Short Investigation Bulletin – Issue 15

ATSB welcomes the reappointment of Ms Carolyn Walsh as a member of the ATSB Commission.

The Australian Transport Safety Bureau (ATSB) welcomed the reappointment of Ms Carolyn Walsh as a member of the ATSB Commission. Ms Walsh’s appointment by the Minister for Infrastructure and Transport, the Hon Anthony Albanese will commence on 8 March 2013 and will run for a further three years.

Ms Walsh has a wealth of experience in the field of transport safety in both policy and regulatory roles. She has specialist expertise in safety (both transport and occupational health and safety), risk management and the regulatory framework governing transport operations in Australia.  She was the Chair of the national steering committee that advised the National Transport Commission on the development of the national Model Bill for Rail Safety.  

Before becoming a Commissioner of the ATSB Ms Walsh was the Chief Executive of the NSW Independent Transport Safety and Reliability Regulator. She is currently a member of a number of Audit and Risk Committees for NSW Government agencies including: Aboriginal Lands Council (Chair), Information and Privacy Commission (Chair), Police Integrity Commission (member) and Office of the Director of Public Prosecutions (member).

The ATSB’s Chief Commissioner, Martin Dolan, said that he welcomes the opportunity to continue working with Ms Walsh to advance the national transport safety agenda. 

Three important lessons have emerged from the ATSB’s investigation into the capsize of the tug Adonis at Gladstone, Qld in June 2011

Three important lessons have emerged from the ATSB’s investigation into the capsize of the tug Adonis at Gladstone, Qld on 11 June 2011:

• Masters of tugs, regardless of size, need to be actively aware of the signs that a tug might be in danger of capsizing and what to do to lessen this danger. 
• In multiple tug operations, masters need to plan the passage and consider the speed of the passage and when it is time to release the towline. 
• It is also essential that masters communicate frequently throughout the passage bring any concerns about speed to the other master’s attention. 

On 11 June the harbour tug Adonis, which had four persons on board, was engaged in an operation with a second tug, Wolli, to move an Australian registered unmanned steel flattop dumb barge (Chrysus) in the port of Gladstone, Queensland. Adonis capsized during the operation. Three of the four persons on board escaped but the fourth drowned in the wheelhouse. 

The tug’s crew were not able to release the towline using the towing hook’s quick release arrangement before the tug capsized.

The ATSB found that while the masters of the two tugs were aware of the risk of capsize, neither of them realised that Adonis had entered a classic capsize scenario when it moved abaft of the barge’s port bow before the barge had begun to slow down. The barge’s speed was not reduced in time to allow Adonis’s master to regain control of the tug and manoeuvre it back into a safe position ahead of the barge. The tug’s crew were not able to release the towline using the towing hook’s quick release arrangement before the tug capsized. 

Investigations into the accident found that the retrospective fitting of a set of ‘H’ bitts to the tug aft of the towing hook had a detrimental effect on the tug’s manoeuvrability. The fitting of the ‘H’ bitts and a towing winch also resulted in Adonis being unstable when undertaking towing operations over the stern. This fact was never identified by the tug’s owners because the tug’s stability was not recalculated after the fitting of the additional equipment. 

Sea Swift, the owners of Adonis, have produced new procedures covering the quick release arrangements on its tugs and enhanced the training and familiarisation of its crews with these arrangements. The company has also reviewed all of its tugs’ towing and quick release arrangements and introduced regular testing of the equipment. They have also implemented a program to review all stability data for tugs purchased overseas. Sea Swift has also employed an experienced training manager to review and monitor the company’s health and safety practices. A review of Sea Swift’s training assessment for new masters has extended the period of training to include mentoring and supernumerary runs with other masters to develop a greater understanding of towing requirements.   

Read the final report: Capsize of the Australian registered tug Adonis, at Gladstone, Queensland, on 11 June 2011

Air traffic control (ATC) local procedures need to be unambiguous and encompass all possible operational circumstances. That is the safety message arising from the loss of separation north of Cairns in November 2011.

Air traffic control (ATC) local procedures need to be unambiguous and encompass all possible operational circumstances. That is the safety message arising from the loss of separation between a Cessna 402C and a Cessna C210 that occurred 6 km north of Cairns, Queensland on 23 November 2011. Effective radar navigation guidance is also important when positioning an aircraft for an approach. 

The C402 was conducting an instrument landing system (ILS) approach for runway 15 at Cairns airport and was 1.8 NM (3.3 km) from the airport when the pilot initiated a missed approach from a height of 1,000 feet in instrument meteorological conditions. At the time, the C210 was on the same ILS approach and was 6.4 NM (11.9 km) behind the C402. About 1 minute after the pilot turned left to establish the aircraft on the missed approach track, the distance between the two aircraft reduced below the required ATC separation standard.

Airservices has amended the local procedure to assist with the clarity and intent...

The ATSB identified that a local ATC procedure published, in part, to assist ATC in separation management during a missed approach event, was not clear and was subject to varying interpretations. This resulted in the spacing between the aircraft being closer than intended when the pilot of the C402 commenced the missed approach. The local procedure did not fully consider all operational aspects that could lead a pilot to initiate a missed approach in instrument meteorological conditions above the procedure-defined minimum cloud base height. 

In response to this occurrence, Airservices has amended the local procedure to assist with the clarity and intent and to enforce minimum flow (distance) spacing, and has updated controller missed approach procedures refresher training. The updated training will increase controller awareness of separation assurance issues relating to consecutive approaches and ensure that controllers give due consideration to the broad range of aircraft types using straight-in approaches. 

Read the final report: Loss of separation between VH-TFK and VH-PDP, 6 km north of Cairns, Queensland, on 23 November 2011

Pilots must provide accurate and complete information on their medical questionnaire and seek medical advice for any condition that could affect their ability to fly safely.

• Pilots should seek the advice of a Designated Aviation Medical Examiner (DAME) if they become aware of any condition that could affect their ability to safely carry out the privileges of their aviation licence.

On 3 September 2011 the pilot and one crewman in a Robinson R-44 helicopter departed an airstrip located near the Kumarina roadhouse, approximately 150 km south of Newman, Western Australia.

The crew were conducting low-level geophysical survey operations when the pilot was observed to have slumped forward in the seat. The crewman, who was seated behind the pilot, made unsuccessful attempts to rouse the pilot. The helicopter subsequently impacted terrain causing significant injuries to the crewman and the pilot. After the impact the pilot regained consciousness but died of his injuries before medical help arrived.

Pilots must provide accurate and complete information on their medical questionnaire and seek medical advice for any condition that could affect their ability to fly safely. 

The ATSB found that the pilot held a Class 1 Aviation Medical Certificate with no restrictions despite inconsistencies in recorded information in the pilot’s aviation medical questionnaires and one previous unconsciousness episode being recorded. If the correct information had been documented, further medical tests may have been required and the results used to better assess the pilot’s medical status.

During the investigation, CASA was advised of the reporting inconsistencies in the pilot’s aviation medical questionnaires. In response, CASA confirmed that the medical section of its website is being reviewed and guidance material on medical issue reporting requirements will be available on the website when the work is complete.

In addition to regular aviation medical assessments, pilots should seek the advice of a Designated Aviation Medical Examiner (DAME) if they become aware of any condition that could affect their ability to safely carry out the privileges of their aviation licence. It is also important for pilots to check the information documented in their aviation medical assessment for accuracy and completeness to allow for accurate assessment of their medical status and any risk to the safety of flight.

Read the final report: Pilot incapacitation while operating a Robinson R44, VH-HCA, 180 km south-south-west of Newman, Western Australia, on 3 September 2011

On 21 January 2013 the ATSB welcomed a delegation from the Republic of the Union of Myanmar. The delegation includes officials from the Myanmar Department of Civil Aviation and the Myanmar Aircraft Accident Investigation Bureau, and representatives from airlines within Myanmar.

On 21 January 2013 the ATSB welcomed a delegation from the Republic of the Union of Myanmar. The delegation includes officials from the Myanmar Department of Civil Aviation and the Myanmar Aircraft Accident Investigation Bureau, and representatives from airlines within Myanmar.

The Australian Transport Safety Bureau is providing specialist assistance to Myanmar with its accident investigation into a Fokker 100 jet that crashed on 25 December 2012. The jet, carrying 71 people, including 5 Australians, landed in a field short of the runway at Heho Airport, which is the portal to the popular tourist destination of Inle Lake. There were fog patches in the area at the time.  Two persons were killed, one a passenger in the plane and the other, a motorcyclist on the ground. The plane was badly damaged when its wings were shorn off and it caught fire. Ten passengers required hospital treatment and a further 26 were taken to hospital for medical checks.

The ATSB’s assistance involves the provision of technical specialists and facilities in Canberra to download and decode data from the aircraft’s flight data recorder and the cockpit voice recorder (commonly referred to as black boxes). This assistance is underpinned in Annex 13 to the Convention on International Civil Aviation, which promotes cooperation between member States internationally and details the protocols to facilitate the provision of such assistance.

Providing such assistance is also consistent with the Minister for Infrastructure and Transport’s statement of expectations of the ATSB that includes the requirement that, subject to available resources, we provide assistance to accident investigations in other countries, in accordance with international protocols. Under these arrangements, Australia provides assistance widely in the Asia-Pacific region and has assisted countries such as New Zealand, Papua-New Guinea and Indonesia, as well as other Pacific Island states.

The ATSB welcomes the opportunity to work with our counterparts in the region. It is hoped that the ATSB’s work will provide significant assistance to the Myanmar investigation and contribute more broadly to the enhancement of aviation safety internationally. These opportunities also provide a valuable means by which the ATSB can develop and exercise the skills and experience of its own specialist investigators.

The ATSB’s Chief Commissioner, Martin Dolan, has just published his latest blog post.

In his post, Martin talks about the ATSB’s expanded role as Australia’s independent national rail safety investigator and the contribution the ATSB will make to prevent future accidents and improve rail safety.

Carburettor icing can have serious safety implications for aircraft. This was shown most recently in an accident near Miranda Downs in Queensland.

Carburettor icing can have serious safety implications for aircraft. This was shown most recently in an accident near Miranda Downs in Queensland. On 6 July 2012, a Robinson R22 Beta was conducting mustering operations when the right skid struck a tree and collided with terrain.

The operator’s investigation into the accident—which examined GPS and Bureau of Meteorology data— found that the combination of temperature and dew point indicated a moderate carburettor icing risk at cruise power and a serious icing risk at descent power.

Pilots are reminded to maintain awareness of the weather conditions that are conducive to carburettor ice formation and closely monitor their aircraft performance during times when the risk exists.

Carburettor ice can occur in temperatures as high as 32° C with high humidity. 

The investigation report AO-2012-091 provides important advice about carburettor icing. You can find this and other investigations in the ATSB’s Aviation Short Investigation Bulletin issue 13. The bulletin highlights valuable safety lessons for pilots, operators and safety managers.

More information:

The following publications provide useful information on carburettor icing and avoidance:

• Robinson Safety Notice SN-25 – 
  Carburettor Ice (95.47 KB)
• Robinson Safety Notice SN-31 – 
  Governor Can Mask Carb Ice (421.32 KB)
• Ice Advice, in Flight Safety Australia, March-April 2006, pages 26-33
• Ice Blocked, in Flight Safety Australia, November-December 2004, pages 31-33
• The ATSB educational fact sheet titled Melting Moments: Understanding Carburettor Icing

The Civil Aviation Safety Authority (CASA) Carburettor icing probability chart(Opens in a new tab/window) can be downloaded from the web or purchased from the CASA Shop

The Robinson Safety Notice SN-38 – 

The following ATSB investigation reports provide further reading on carburettor icing:

• ATSB Report AO-2010-107
• ATSB Report AO-2009-031

Systemic safety issues in Queensland coastal pilotage operations have been identified in an Australian Transport Safety Bureau (ATSB) investigation report.

Coastal pilots form a key defence against a serious shipping incident in parts of the Great Barrier Reef and Torres Strait as part of a suite of broader protective measures already in place.

The ATSB began an investigation into coastal pilotage operations in December 2010 following the release of its report into the grounding of the piloted tanker Atlantic Blue in the Torres Strait and a request from the Australian Maritime Safety Authority (AMSA)—the coastal pilotage safety regulator. That report identified safety issues affecting coastal pilotage which indicated that other systemic issues may also exist that would benefit from the ATSB further investigating.

The ATSB’s safety issue investigation found that under the coastal pilotage regulations, no organisation, including the pilotage provider companies, has been made clearly responsible and held accountable for managing the safety risks associated with pilotage operations. This has meant that responsibility for managing the most safety critical aspects of pilotage has rested with individual pilot contractors instead of an organisation that systematically manages safety risk.

The investigation also identified systemic safety issues surrounding pilot training, fatigue management, incident reporting, competency assessment and use of coastal vessel traffic services.

AMSA has already taken and proposed safety action to address the issues identified and is working with pilots, pilotage providers and industry to make further improvements to shipping safety in the region. Significant AMSA action includes the publishing of standard passage plans for pilotage, and requiring pilotage providers to develop standard operating procedures for pilotage tasks undertaken by their contractor pilots. On 1 July 2012, AMSA also began a review of its coastal pilotage regulations.                                          

The ATSB welcomes AMSA’s response but considers further action is necessary to fully address the safety issues. In particular, the ATSB is recommending that AMSA ensures that the coastal pilotage regulations specifically assign responsibility for the safe management of pilotage operations to the pilotage providers or another organisation.

The ATSB has also issued recommendations to the three coastal pilotage providers to take safety action in relation to fatigue management and incident reporting to facilitate action by AMSA.

Following the allowed 90-day period after the issue of its recommendations, the ATSB will reassess the safety risk based on the action taken and proposed by AMSA, and the pilotage providers to address the issues.

Read the final report: Safety issue investigation into Queensland Coastal Pilotage