This contact form is intended for use during Major Accident Response scenarios. If you need to contact the ATSB, please visit the contact page.
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At 11.35am today (15 September 2022) a twin-engine airliner operated by ‘No Fuss Airlines’ made an emergency landing at Long Green Grass Airport, Western Australia.
Smoke and flames were seen coming out of the right engine, as well as parts of the aircraft have detached up upon landing (landing gear and part of the right wing). The ATSB understands multiple people have been injured, however no further information as to the health status of any individual passenger is currently available to the ATSB.
The ATSB is appealing for witnesses to the accident to contact them on their Major accident witness hotline and will be publicising a 1800 992 986 number which will be forwarded to Services Australia to log initial calls.
ATSB investigators will follow up with witnesses as soon as possible after the event.
Contacting the ATSB:
Select the 'REVIEW AND SUBMIT' button above, then the 'SUBMIT FORM' button.
All occurrence investigations progress through a series of phases in accordance with the ATSB’s investigation methodology to ensure a rigorous and comprehensive investigation report with evidence-based findings that lead to improvements in transport safety.
Evidence collection
During the evidence collection phase, investigators build a detailed picture of the occurrence or other transport safety matter being investigated. Evidence gathered may include:
site observations and mapping, including recording wreckage distribution and witness marks
relevant components and wreckage, materials and recorded data (including on-board flight, voyage and event recorders, GPS, images, video, system equipment data, and voice recorders) for subsequent analysis
human performance information such as work and rest patterns and time awake, workload, perceptual limitations, communications, and social norms
testing or procuring test and examination reports such as fuel quality-tests, toxicology, functional tests, manufacturer’s test procedures, simulation studies, meteorological analyses
interviews with involved parties, witnesses and subject matter experts
operational records such as logbooks, technical logs, maps or charts, trip reports, weather observations, job sheets, repair records, training records and performance checks, and audit reports
technical documentation such as procedures and manuals, training manuals, maintenance manuals, troubleshooting guides, design drawings and system safety assessments, and
data on similar occurrences in Australia and overseas and other occurrence data.
Examination and analysis
ATSB investigators use the collected evidence to build a detailed understanding of the circumstances surrounding the occurrence (or other transport safety matter) being investigated. This involves evidence interpretation, safety factors analysis, risk analysis and analysis review activities, as shown in the following diagram:
Evidence interpretation involves a series of activities to review, examine, organise and interpret the collected evidence and convert this evidence into formats that assist the analysis of safety factors. ATSB investigators may:
undertake detailed data analysis
create simulations and reconstruct events
examine company, vehicle, regulator and other records
examine wreckage and test components and system in the ATSB’s technical facilities
research scientific literature related to human factors or other topics associated with the evidence
review specialist reports (such as meteorology, component examination, post-mortem report and toxicology reports) and consult with relevant experts
conduct further interviews
determine the sequence of events
review related occurrences, and
compare evidence from multiple sources to look for similarities, differences, patterns and trends.
Examination and analysis requires evaluating complex sets of data, and the available evidence can be vague, incomplete and or contradictory. The review of the evidence may prompt the collection of more evidence, which in turn needs to be analysed and examined, potentially adding to the length of an investigation.
Once the examination and interpretation of the evidence about a topic is complete, the investigation team will develop and test a series of hypotheses to determine the contributing factors and other factors that increased risk. This involves conducting test for existence and influence, and evaluating the relevance and credibility of the reasons and evidence that support and oppose each hypothesis.
During the examination and analysis phase, the investigation team convenes one or more safety factor reviews with ATSB management. These are rigorous internal reviews of the progress of the investigation, its findings, scope and schedule. A safety factor review involves the investigation team presenting their evidence and analysis to reach consensus on the investigation findings. Once consensus is achieved on all the findings, the safety analysis section of the draft report can begin.
Final report: Drafting
Most ATSB reports contain the following sections:
Investigation summary—a summary of the occurrence (or other transport safety matter), the findings and any safety action taken as a result, as well as any broader safety messages.
The occurrence—a description of the sequence of events related to the occurrence and, if relevant, the consequences in terms of injuries and damage.
Context—description of evidence collected during the investigation that is necessary to help the reader understand the occurrence and safety analysis, or the broader safety issues for research purposes.
Safety analysis—a demonstration of how the evidence justifies the investigation findings
Findings—a list of contributing factors, other factors that increased risk and other findings identified during the investigation and discussed in the safety analysis.
Safety issues and actions—a summary of the safety issues that were identified during the investigation and details of what safety action has been taken, or is planned to be taken, by relevant parties to address those issues.
During the drafting of the report it may be necessary to return to the evidence collection or examination and analysis phases of an investigation. There will often be significant overlap in time between the evidence collection, examination and analysis and final report drafting phases.
Final report: Internal review
Final ATSB investigation reports undergo a rigorous internal review process to ensure the report adequately and accurately reflects the evidence collected, analysis, and agreed findings of the Safety Factor Review. Final investigation reports also undergo other technical and administrative reviews to ensure the reports meet national and international standards for transport safety investigations.
If a review identifies any issues with a report, such as information that needs to be expanded or findings that need to be modified, investigators will look to collect new evidence or conduct additional examination and analysis of existing evidence.
Final report: External review
To check factual accuracy and ensure natural justice, Directly Involved Parties (DIPs) are given the opportunity to comment on the final report before it is approved to ensure their input to the investigation has been accurately reflected.
DIPs are individuals or organisations outside the ATSB who possess direct knowledge of the circumstances surrounding the incident or accident.
Draft reports are provided to DIPs under Section 26(1)(a) of the Transport Safety Investigation Act 2003. Under Section 26, the report may only be copied and disclosed for the purpose of taking safety action or providing comment to the ATSB. Anyone who receives a copy for these purposes is also bound by the confidentiality requirements.
Disclosure of the draft report in any other circumstance may constitute a criminal offence.
ATSB draft reports may contain information that is subject to change as a result of internal and external review and consideration of further evidence. In its draft form, copying or disclosing the report may unjustly affect reputations. This in turn could potentially impede and discourage the crucial, future free flow of safety information to the ATSB.
Following the external review process, the report is approved by management before being sent to the ATSB Commission for final approval. Once approved, the final report is prepared for publication and dissemination and released to DIPs prior to its public release.
Final report: Dissemination
Once an ATSB report is approved, it is prepared for public release and approved safety issues and recommendations are formally communicated to the relevant parties.
The report is then released publicly on the ATSB website and shared on social media, to ATSB subscribers via email and with the media. For certain investigation releases the ATSB may also produce an explanatory video(Opens in a new tab/window).
The progress of safety action to address ATSB recommendations is tracked and communicated, on an ongoing basis, via the ATSB website.
If you have witnessed an incident or accident – or have information that could be of relevance to an ATSB investigation – please call 1800 992 986 or (+61) 2 6257 3193.
This contact form is intended for use during Major Accident Response scenarios. If you need to contact the ATSB, please visit the contact page.
The ATSB has been advised of .... The ATSB is investigating this accident.
Police and emergency services are on site.
We understand multiple people are injured.
Concerned family and friends need to <operator's> hotline to be kept informed as to the wellbeing of the passengers on board the flight. • (Within Australia): 1800 XXX XXX • (International callers) +61 X XXXX XXXX
The ATSB has deployed a team of investigators to the accident site.
While on-site the investigators will be:
examining the wreckage for evidence
interviewing witnesses and survivors as well as people involved in the aircraft operation
examining documentation relating to the airworthiness, maintenance history, company operation, flight crew qualification, air traffic records
recovering the flight data recorder and cockpit voice recorder to download in our Canberra facilities.
Other investigators will be called in, depending on what is found during the initial stages. ATSB staff back in our offices are also collecting relevant data from other sources that may also shed some insight into the nature of this accident.
To help us with our investigation, we are asking witnesses to complete the form below or call the ATSB on 1800 992 986.
We will be releasing more information as it come to hand.
We will publish a preliminary investigation report within the next month, detailing what factual information has been obtained so far.
Contacts:
Family and friends – please contact <Operator's> hotline: 1800 XXX XXX
Media outlets – to receieve email updates on this investigation, please send your contact details to: media@atsb.gov.au
Witnesses – please contact the ATSB on 1800 992 986 or complete the below form
Overseas investigation agencies – please contact the ATSB on +61 2 6257 XXXX or via email: atsbinfo@atsb.gov.au
With the exponential increase in the number of RPAS in Australia, the number of near collisions with manned aircraft has also increased.
The growth in the number of remotely piloted aircraft systems (RPAS) in Australia is increasing rapidly. This presents an emerging and insufficiently understood transport safety risk.
Over half of all occurrences involving an RPAS reported to the ATSB are near encounters with manned aircraft – almost half involve high capacity air transport aircraft.
To date, there have been no reported collisions between RPAS and manned aircraft in Australia.
Due to the rarity of actual collisions, the ATSB has examined various experimental studies and mathematical models to predict damage expected from collisions between RPAS and manned aircraft. These are informed by abundant aircraft birdstrike data.
RPAS collisions with high capacity air transport aircraft can be expected to lead to an engine ingestion in about eight per cent of strikes. The proportion of ingestions expected to cause engine damage and engine shutdown will be higher than for bird ingestion (20 per cent of ingestions).
RPAS have the potential to damage a general aviation aircraft’s flight surfaces (such as the wings and tail), which could result in a loss of control. Rotorcraft blades are expected to be particularly susceptible to damage due to the invariably high impact speeds. Furthermore, a collision with a general aviation aircraft’s windscreen poses a high risk of penetration.
The ATSB has investigated a number of incidents and accidents where fatigue was identified as having a causal effect.
Human fatigue is a physical and psychological condition primarily caused by prolonged wakefulness and/or insufficient or disturbed sleep. Everyone has experienced fatigue at some point, but in the transport industry, where there’s often high pressure to deliver, fatigue can have very real, very dangerous implications.
Fatigue can have a range of adverse influences on human performance, such as slowed reaction time, decreased work efficiency, reduced motivational drive, and increased variability in work performance. Fatigue can lead to lapses or errors associated with attention, problem-solving, memory, vigilance and decision-making.
Experiencing fatigue and its effects on performance is a widespread issue across the transport industry. ATSB investigations have found fatigue to be a safety factor in many rail, marine and aviation incidents and accidents. Investigators will check for the possibility of fatigue as a contributing safety factor in investigations where human performance issues are apparent.
Most people generally underestimate their level of fatigue. Studies have found that people experiencing fatigue are not able to evaluate accurately their own fatigue level or their ability to perform. Instead, they tend to overestimate their abilities.
What can you do?
Minimising fatigue is a responsibility for both employees and employers. Sleep is vital for recovery from fatigue, with both the quantity and quality of sleep being important. Most people need at least seven to eight hours of sleep each day to achieve maximum levels of alertness and performance.
Employers: Employers have a duty of care to provide safe work schedules that permit adequate time for an employee to sleep, rest and recover, as well as fulfil their social and domestic responsibilities. In doing so, organisations should provide adequate time for their staff to get the required restorative sleep opportunity, sufficient time for recovery including meals, hygiene and rest, as well as enough time to travel to and from suitable sleeping accommodation.
Employees: Employees should ensure they use any rest periods provided to obtain adequate sleep where possible. They also have a duty of care to use their time away from work to get enough sleep and recovery time so they can complete their work duties safely and responsibly.
The following questions can help you assess your risk of elevated fatigue at any time:
Have you missed gaining adequate sleep over the past few nights?
Have you had less than six hours sleep in the last 24 hours?
Have you had less than 14 hours sleep in the past 48 hours?
Has your sleep been disrupted?
Have you been awake and/or at work for an extended period?
Have you had a recent illness or injury?
Are you affected by medication, other drugs or alcohol?
If you have answered yes to one or more of these questions, you are at a higher risk of fatigue.
Culture: In the transport industry, when there’s so much emphasis on hitting schedules, and getting cargo and passengers to their destinations, there can be cultural pressure to ‘power on through’ and ‘just get it done.’ Even though there are laws which restrict the hours that people can be made to work, there are sometimes unofficial policies to stretch people’s hours or enter incorrect duty times. In circumstances like these, it can be difficult to speak up.
For situations like this, the ATSB maintains REPCON, a voluntary confidential reporting scheme for aviation, marine, and rail. It allows any person who has a safety concern to report it to the ATSB confidentially. Protection of the reporter’s identity is a primary element of the scheme.
It is difficult for pilots to identify other aircraft through visual observation alone.
The ATSB often receives reports from pilots that another aircraft is flying too close to them in uncontrolled airspace. Not surprisingly, three quarters of these reports involve pilots flying within 10 nautical miles (18.5 kilometres) of a non-controlled aerodrome.
In nearly three quarters of all near-collisions reported to the ATSB, at least one pilot had no prior warning of the other aircraft in their vicinity.
Insufficient communication between pilots operating in the same area is the most common cause of safety incidents near non-controlled aerodromes.
There have been numerous accidents worldwide that were the result of simple human errors in data calculation or entry.
Data errors—such as the wrong figure being used as well as data being entered incorrectly, not being updated, or being excluded—happen for many different reasons.
The consequences of these sort of errors can range from aborted take-offs through to collisions with the ground. Errors can occur irrespective of pilot experience, operator, aircraft type, location and take-off performance calculation method.
An increasing trend has been identified where pilots do not effectively manage their aircraft’s flightpath when unexpected events arise during the approach to land.
When compared to other phases of flight, the approach and landing has a substantially increased workload and is traditionally the phase of flight associated with the highest accident rate. Flight crews must continuously monitor aircraft and approach parameters, and the external environment, to ensure they maintain a stable approach profile and make appropriate decisions for a safe landing.
The selection of inappropriate autoflight modes, unexpected developments, or any confusion about roles or procedures can contribute to decisions and actions that increase the safety risk to the aircraft and its passengers.
The ATSB has investigated several accidents that have occurred when maintenance work was being carried out on or near railway tracks.
Conducting work on or near a railway track can be dangerous if safeworking rules and procedures have not been correctly implemented to protect the worksite. Trains cannot stop quickly and any breakdown in the communication or management of a worksite can leave workers extremely vulnerable to dangerous situations.
