Fatal accident prompts safety recommendations for skydiving operations

A multi-fatal accident involving a Cessna U206G aircraft has resulted in the ATSB issuing recommendations to improve the safety of skydiving operations in Australia.

The 22 March 2014 accident occurred when the aircraft was conducting tandem parachuting operations at Caboolture in Queensland. On board were the pilot, two parachuting instructors and two tandem parachutists.

Shortly after take-off, the aircraft climbed to about 200 feet before aerodynamically stalling and colliding with the ground. Tragically, all five died in the accident.

ATSB Chief Commissioner Greg Hood said the investigation report, released today, reveals that extensive fire damage prevented examination and testing of most of the aircraft components.

“Due to the post-impact damage to the aircraft, we couldn’t rule out a mechanical defect as a contributor to this accident,” Mr Hood said.

“Importantly, our investigation did uncover a number of safety issues associated with occupant restraint, modification of parachuting aircraft and scope for improving the risk controls associated with parachuting operations.”

In response to the ATSB’s investigation, the Australian Parachute Federation (APF) and Australia’s aviation safety regulator, CASA, undertook action to improve safety of parachuting operations.

“The APF mandated that all member clubs/operations have their own safety management system to proactively assess and mitigate risks. The APF has also enhanced their audit process and increased the number of full-time safety personnel to audit their member organisations.” Mr Hood said.

“The Civil Aviation Safety Authority (CASA) has increased the available information on their website about the risks associated with sports aviation. CASA also introduced an Airworthiness Bulletin to provide guidance about co-pilot side flight control modifications.

“We welcome APF’s and CASA’s safety action but consider more can be done to improve safety for skydiving operations.”

In response to an identified safety issue, the ATSB recommends that CASA take safety action to increase the fitment of the Cessna secondary pilot seat stop modification. This safety issue affects all Cessna Aircraft and not just those being used for parachuting operations.

In addition, it is recommended that CASA introduce measures to reduce the risk associated with the aviation aspect of parachuting operations.

As well, the ATSB recommends CASA and the APF increase the use of dual-point restraints in parachuting aircraft.

Under legislation, APF and CASA have 90 days to respond to the ATSB’s recommendations.

Read the final investigation report AO-2014-053

As the accountable authority for the Australian Transport Safety Bureau (ATSB), I am pleased to present the ATSB’s 2017–18 Corporate Plan, which covers the period 2017–18 to 2020–21.

This Corporate Plan sets out the ATSB’s purpose – to improve transport safety – and its strategies for achieving that purpose. The Plan also sets out the ATSB’s key deliverables and associated performance criteria. It has been prepared consistent with paragraph 35(1)(b) of the Public Governance, Performance and Accountability Act 2013 and the relevant provisions of the Transport Safety Investigation Act 2003 (the TSI Act), which establishes the ATSB. It also covers the Minister for Infrastructure and Transport’s Statement of Expectations (SOE ) as notified under Section 12AE of the TSI Act.

The TSI Act provides that the ATSB’s primary purpose is to improve the safety of aviation, rail and marine transport through accident investigation, data analysis and safety education. It must do so independently while cooperating with the other organisations that share responsibility for transport safety, including counterpart organisations in other countries. Successive governments have indicated that, in carrying out its role, the ATSB should give priority to the safety of the travelling public.

To accomplish its primary purpose, the ATSB must take into account the known and projected environmental challenges associated with continuing growth, emerging technologies and safety trends across the aviation, rail and marine transport sectors. In response, the ATSB has implemented a significant reform agenda that will position the agency to evolve its capabilities to deliver core functions in a more efficient and effective manner. A key enabler to this reform agenda has been the Government’s recent budget measure that will assist the ATSB in maintaining a sustainable resource base.

Through its contemporary workforce planning strategies, the ATSB will strive to attract, develop and retain the best people, with the requisite skills, knowledge and experience to meet the current and emerging challenges in transport safety investigation.

In my capacity as Chief Commissioner and Chief Executive Officer, I am fully committed to maintaining the ATSB’s reputation as a world leading safety investigation body. Consistent with this commitment, I will work collaboratively with the relevant authorities to ensure the ATSB is appropriately resourced to fulfil its legislative duties and positioned to meet the expectations of our stakeholders and the broader travelling public.

Greg Hood
Chief Commissioner

30 August 2017

 

Penalties

Section 26 of the Transport Safety Investigation Act 2003 (TSI Act) imposes a maximum penalty of two years imprisonment for a person who discloses the contents of a draft report to any other person or to a court. The maximum penalty for unauthorised copying of the whole or any part of a draft report is $3,600.

The reason for the penalties for unauthorised copying and disclosure of a draft report is that it 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 businesses and reputations. This in turn could potentially impede and discourage the crucial free-flow of safety information to the ATSB.

Section 26(4) of the TSI Act provides that the penalties do not apply where copying or disclosure is necessary for the purpose of preparing a submission to the ATSB on a draft report, or for taking steps to remedy safety deficiencies that are identified in the draft report. A person who receives a copy of the draft report may wish to copy it and disclose it to technical experts and legal representatives for input into their submission to the ATSB. Anyone who receives a copy of the draft report for the purpose of providing such assistance is subject to the confidentiality requirements of the TSI Act.

Referral to the AFP

Where a draft report has been disclosed in breach of s.26(2) of the TSI Act (for example in a leak to the media), the disclosure will be assessed to determine the appropriate action to be taken. The apparent breach of s.26(2) will likely be referred to the Australian Federal Police (AFP) for investigation. The AFP may then provide a brief of evidence to the Commonwealth Director of Public Prosecutions (CDPP) to consider prosecution of the alleged offence.

The ATSB’s policy is that an unauthorised disclosure of a draft report will be referred to the AFP for investigation where it is clear that:

1. The disclosure was not made for the purposes of subsection 26(4) of the TSI Act; and

2. The person who made the unauthorised disclosure was aware of the confidentiality requirements of s.26 or should have in the circumstances been aware of those requirements, and there is evidence that the person making the disclosure:

(a)    deliberately decided to make the disclosure notwithstanding the confidentiality requirements of s.26; or

(b)   was reckless in making the unauthorised disclosure; and

3. The disclosure would be likely to lead to the information being taken out of context or misused and, as a result, prejudicing that particular investigation or future investigations, or unnecessarily and unjustly tarnishing reputations; and

4. An investigation by the AFP, with potential prosecution by the CDPP, is thought necessary to deter breaches of s.26(2) in that or any other investigation.

redirected page

As the accountable authority for the Australian Transport Safety Bureau (ATSB), I am pleased to present the ATSB’s 2016–17 Corporate Plan, which covers the period 2016–17 to 2019–20.

This Corporate Plan sets out the ATSB’s purpose, its strategies for achieving that purpose and how the effect of the strategies and the attainment of the ATSB’s purpose will be measured. It has been prepared consistent with paragraph 35(1)(b) of the Public Governance, Performance and Accountability Act 2013. The Plan takes account of the relevant provisions of the Transport Safety Investigation Act 2003 (the TSI Act), which establishes the ATSB. It also has regard to the views of the Minister for Infrastructure and Transport on the ATSB’s strategic direction as notified under Section 12AE of the TSI Act.

The TSI Act provides that the ATSB’s primary purpose is to improve the safety of aviation, rail and marine transport through accident investigation, data analysis and safety education. It must do so independently, but in cooperation with the other organisations that share responsibility for transport safety, including counterpart organisations in other countries. Successive governments have indicated that, in carrying out its role, the ATSB should give priority to the safety of the travelling public.

To accomplish its primary objective, legislated key functions and broader portfolio responsibilities, the ATSB must take into account the financially constrained environment in which it operates. Since becoming an independent statutory authority in July 2009, the ATSB’s base appropriations have continued to reduce over successive financial years with further reductions projected over the forward estimates. Within this setting the ATSB must also remain vigilant of the opposing continued growth in, and progressive changes to, the composition of the aviation, rail and marine transport sectors.

In response, the ATSB will need to further enhance its data-driven approach to transport safety through increasing its capacity to carefully analyse available occurrence data. This will enable the ATSB to selectively allocate its limited resources towards investigating those accidents and incidents that will have the greatest potential for safety learnings and enhancement. It will also expand the ATSB’s capacity to identify emerging threats to transport safety.

The ATSB strives to maintain the people, information and systems to be a world leader in its field. This includes having the residual capability to manage an immediate and sustained response to a significant transport safety event, whether it be a major accident or, as is the current case, to undertake a major safety project such as the search for the missing Malaysia Airlines flight MH370. The ATSB’s ability to meet this overarching responsibility will remain subject to the limitations imposed by increasingly constrained resources and growing demands.

As the recently appointed Chief Commissioner, I am fully committed to maintaining the ATSB’s reputation as a world leading safety investigation body. Consistent with this commitment, I will work collaboratively with the relevant authorities to ensure the ATSB is appropriately resourced to fulfil its legislative duties and positioned to meet the expectations of our stakeholders and the broader travelling public.

Greg Hood
Chief Commissioner
31 August 2016

Applying for a position overseas?

If you are applying for a position overseas and the organisation wants a letter of verification of your Flight Crew Licence (FCL), the Civil Aviation Safety Authority (CASA) can issue a standard letter reflecting your qualifications including:

• Australian Flight Crew Licence (Including endorsements; ratings and approvals)
• Aviation Reference Number (ARN)
• Current Aviation Medical details including any conditions attached to the Certificate
• Details of any suspensions / cancellation of my Flight Crew Licence and any actions brought against me by CASA.

Apply to CASA, as the issuer of your licence, for a FCL Verification Letter by completing the Flight crew licence verification form 452(Opens in a new tab/window) (PDF 164 KB)

Further information, email: CLARC@casa.gov.au, call 131 757, or visit CASA flight crew licensing FAQs(Opens in a new tab/window)

Aviation Incident Reporting Summary

ARN holders can be provided with an Aviation Incident Reporting Summary to confirm any accidents and incidents reported to the ATSB.

Accidents and serious incidents (commonly called (Opens in a new tab/window) Immediately Reportable Matters), which affect the safety of aircraft must, in the first instance, be notified to the ATSB by telephone (24 hours) 1800 011 034. During business hours you can also call (+61) 2 6230 4470.

Accidents and serious incidents are required to be immediately notified to the ATSB in accordance with section 18 of the Transport Safety Investigation Act 2003. The ATSB collects information for the purposes of enhancing transport safety. The collection of aviation accident and incident information is required in connection with the Transport Safety Investigation Act 2003.

Written notifications are required to be submitted within 72 hours of an accident, serious incident or incident in accordance with section 19 of the Transport Safety Investigation Act 2003 and contain the particulars set out in the Transport Safety Investigation Regulations 2021. The written notification should contain as much information about the accident, serious incident or incident as is within the knowledge of the person at the time of submitting the notification.

If you cannot complete this notification or require assistance, please telephone 1800 011 034.

Disclosure of information (including personal information)
The ATSB’s function of improving transport safety through receiving reports and conducting investigations may include sharing safety information with other organisations or persons who are best placed to make improvements to transport safety.

If information is shared by the ATSB, it will remove information that directly identifies an individual where possible (i.e. names, licence numbers and addresses). However, other indirect identifiers (i.e. times, dates and locations for the occurrence of incidents) could be disclosed in the interests of safety. If the information is the subject of an ATSB investigation it will only be used and shared in accordance with the strict limitations set out in the Transport Safety Investigation Act 2003(Opens in a new tab/window). The ATSB also handles information you provide in accordance with its Privacy Policy.

Information disclosed to CASA

The ATSB and CASA have developed a mandatory notifications information sharing policy. The policy outlines the requirements for the information and provides advice on the manner in which it will be used when shared between the two agencies.

False or misleading reports
Submission of information known by the reporter to be false or misleading is a serious offence under section 137.1 of the Commonwealth Criminal Code. It is also a serious offence for a person to assist another person to provide false or misleading information. 

Security
This form is submitted securely.

Subsection 49(3) notice for the voice component of the voyage data recording recovered by ATSB after Shen Neng 1’s grounding at Douglas Shoal on 3 April 2010

The ATSB has issued a notice under s.49(3) of the Transport Safety Investigation Act 2003 (TSI Act) declaring the voice component of the voyage data recording not to be an on-board recording (OBR) for the purposes of Division 1, Part 6 of the TSI Act.

Pursuant to section 49 of the Transport Safety Investigation Act 2003, I declare that the whole of the identified recording (recovered by the ATSB on 9 April 2010) is not to be treated as an OBR on and after 14 April 2011 (the date of publication of ATSB’s final investigation report into the grounding).

Martin Dolan
Chief Commissioner

These operational reports have been developed to provide regular updates on the progress of the search effort for MH370.

Most recent at top

These videos are presented to promote the activities of the Australian Transport Safety Bureau (ATSB) and transport safety.

• Visit the ATSB on YouTube(Opens in a new tab/window) for more.