The Australian Transport Safety Bureau (ATSB) 2011–12 Annual Report outlines performance against the outcome and program structure in the 2011–12 Infrastructure and Transport Portfolio Budget Statements.

Chief Commissioner’s review 2011–12

This was the third year of the ATSB in its current form as a fully independent agency within the Infrastructure and Transport portfolio. The ATSB now has well developed business systems and governance arrangements to support its activities as Australia’s independent transport safety investigator. Our solid underpinnings have enabled us to expand our safety research, analysis and education functions.

At year’s end we had 56 larger aviation investigations on hand which represents a stable workload. This year only four of those investigations are over one year old, which demonstrates that we have reached a sustainable level of activity that allows us to meet our targets for timely investigation while maintaining the high quality of our work. The number of investigations in marine and rail has remained stable with 10 and 14 investigations outstanding.

Our short investigations have become a substantial component of our work. We released 90 short investigation reports in the past year. The capacity to undertake a larger volume of these short investigations provides excellent opportunities to deliver safety messages and for industry participants to learn from the experiences of others. In addition, although many of these investigations examine occurrences that are common and for which the underlying factors are well known, they serve to enhance the quality of the data held by the ATSB and act as a safety net to identify situations where more detailed or extensive investigation may be warranted.

This year we had a strong focus on engaging with our stakeholders and working even harder to disseminate our safety messages to ensure that they are understood and are acted upon. Our stakeholder survey gives us confidence that we are heading in the right direction but we recognise that we need to get even better at safety communication. This year we ventured into social media, using Twitter to let our stakeholders know about key issues and the release of our reports. This has proved very effective.


The aviation investigation teams completed 11 complex and 127 less complex (includes 90 short) aviation accident and incident investigations during the past year. As usual several of these were of considerable national and international interest, identifying a number of safety issues that elicited commendable safety action by the relevant parties to reduce risk to the travelling public. These included:

  • AO2008070. Injuries sustained by passengers and crew during the in–flight upset that occurred west of Learmonth, Western Australia on 7 October 2008 and involved a Qantas Airbus A330–303 (A330) aircraft, registered VH–QPA, reinforced the safety benefits of passengers having their seat belts fastened whenever they are seated. The upset resulted from a very rare series of intermittent, incorrect output spikes from one of the aircraft’s three air data inertial reference units (ADIRU). These data spikes were not appropriately processed by the aircraft’s flight control primary computers (FCPC), which then commanded the aircraft to pitch nosedown. In response to this accident, the aircraft manufacturer revised the aircraft’s operational procedures to manage any repetition of the data spikes in the A330 and the ADIRU manufacturer modified the ADIRU to minimise the risk of a recurrence of the incorrect data spikes. In addition, the aircraft manufacturer incorporated revised software standards into the FCPC to prevent erroneous ADIRU data affecting aircraft pitch control.
  • AO2009012. The investigation into the tail strike and runway overrun that occurred at Melbourne Airport, Victoria on 20 March 2009 involving an Emirates Airbus A340–541 aircraft, registered A6ERG, confirmed the fallibility of any system that relies on human input, particularly in the face of in–cockpit distractions. In this case, inadvertent and incorrect data entry into the aircraft’s performance systems could have resulted in the loss of the aircraft. Of importance, the investigation found that the use of erroneous take–off performance parameters was not new, and has occurred over time across a range of aircraft types, operators, operations and locations. Equally significant was that degraded take–off performance was generally not detected by flight crew until well into the take–off run (if at all), and that the take–off performance philosophy in civil transport aircraft did not require crews to monitor their aircraft’s acceleration or provide a required reference acceleration. In response, the operator and aircraft manufacturer undertook a number of procedural and equipment based safety actions. This included the commencement of the development of software that will detect discrepancies between the take–off speeds and check that the aircraft has sufficient runway length to support a takeoff.
  • AO2010019. The report into the crash of an Air North Embraer Brasilia aircraft, registration VH–ANB at Darwin Airport, Northern Territory highlighted the importance of the action by the Civil Aviation Safety Authority (CASA) to mandate the use of simulators for non–normal flying training and proficiency checks in larger aircraft. CASA has subsequently advised of changes to the simulator–based training requirements for such aircraft that will come into effect on 1 April 2013 and encouraged air operators to prepare early for the new rules. The flight had been for the purpose of revalidating the command instrument rating of the pilot under check and was under the command of a training and checking captain, who occupied the copilot’s seat. The takeoff included a simulated engine failure which led to a loss of control and the deaths of the two pilots.
  • In aviation, we are continuing our work to understand and mitigate the number of breakdowns of separation (BOS) and losses of separation assurance (LOSA) in air traffic control. Although the rate of these occurrences this year was broadly reflective of earlier years, we continue to examine individual occurrences in order to prevent their recurrence, but have also initiated a safety research investigation to bring the results of completed investigations together and compare their results with each other and the overall occurrence data set. To date, no significant, systemic safety issues have been identified as a result of our ongoing assessment of BOS/LOSA occurrences. If they had, the ATSB would already have drawn it to the attention of Airservices Australia or the Department of Defence so that they could begin safety action in response. If any significant, systemic safety issue is identified in the future, it will immediately be brought to these organisations’ attention.


The marine investigation team completed 10 investigations during the year, two of which were particularly significant for safe work in and around ships.

  • MO2010002. The report into the death of a stevedore who was crushed between two containers during loading operations on board the container ship Vega Gotland, while it was berthed at the Patrick Terminals Port Botany facility identified some very important safety issues for workers handling cargo in loading facilities. The ATSB investigation found that the lashing team leader had placed himself in a position of danger and that when a twistlock foundation unexpectedly failed during the repositioning of the container, he was unable to get clear of the swinging container. The investigation identified that while the dangers of working between a moving container and a fixed object were taught to Patrick Terminals’ new employees during their induction training, the issue was not specifically covered or reinforced in the company’s safe work instructions, the hazard identification and associated risk control processes nor, in some instances, followed in practice by stevedores on board the ships in the terminal. The ATSB identified safety issues during the investigation and Patrick Terminals undertook extensive work to correct the causal issues in this accident.
  • MO2010004. On 16 May 2010, the chief engineer, second mate and fourth engineer of the Isle of Man registered liquefied natural gas tanker British Sapphire were injured when the fast rescue boat they were in dropped 18 m to the water while being launched. The second mate and fourth engineer were part of the rescue boat’s three crew involved in an attempt to transfer the chief engineer to a police launch for medical evacuation. The investigation determined that, in the process of lowering the rescue boat, the wave compensator mechanism on the fast rescue boat’s davit was activated early, before the rescue boat had reached the water. A fail–safe interlock device should have prevented this by placing the wave compensator into standby mode, only becoming operational when the fast rescue boat was waterborne. However, the electrical installation of the interlock was incorrect and meant it could not work as designed, allowing the wave compensation unit to operate always and the fast rescue boat to make the uncontrolled descent to the sea. The investigation identified safety issues relating to the commissioning, maintenance, testing, operating instructions and procedures for the fast rescue boat’s wave compensator and its safety interlock system. Further safety issues were identified relating to the job hazard analysis for the use of the fast rescue boat, crew resource management principles and approved training courses for fast rescue boats. During the investigation, the ATSB was satisfied that the safety action taken by BP Shipping and Davit International addressed the identified safety issues. However, the ATSB remained concerned about the adequacy of training in the use of wave compensation units on fast rescue boat davits and released a safety advisory notice to national and international maritime training institutions about this safety issue.


The Rail Investigation Team completed 12 investigations during the year. Two of these highlighted significant safety issues.

  • RO2010004. In May 2010 a collision between an XPT passenger train and a track–mounted excavator near Newbridge, NSW resulted in the death of the excavator operator. The workers were operating under Track Occupancy Authorities (TOA) and had been authorised to occupy and work on the tracks. Neither the Protection Officer (PO) nor the Network Control Officer (NCO) had positively identified the location and type of worksite.Their actions were influenced by a deficiency in the TOA form, in that no provision was provided to record this critical information. Both the PO and the NCO had wrongly assumed that the train had already passed beyond the limits of the worksite. The problem was compounded when the workers accessed the danger zone before the PO had put in place the normal site protection measures such as detonators and flags. As a result, the Australian Rail Track Corporation (ARTC) reinforced the rules and procedures for the issuing of TOAs. The ARTC also implemented a revised TOA form that records critical information about the location and type of worksite.
  • RO2010015. A freight train 1MP5 derailed on the Trans–Australian Railway Line at Goddards, approximately 240 km east of Kalgoorlie in Western Australia. The derailment occurred within a recently constructed crossing loop on a section of track managed by the ARTC. Train 1MP5 consisted of two locomotives hauling two crew vans and 49 wagons. There were no injuries as a result of the derailment but 23 wagons derailed, many of which were significantly damaged (including all triple–deck car carrier wagons) and about 700 m of track required replacement. The ATSB determined that the derailment was a result of flange climb initiated by a track misalignment which probably grew as train 1MP5 traversed it, initiating the derailment. Factors that contributed to the misalignment were the high ambient temperature, inadequately de–stressed rail and insufficient ballast through the derailment site. The ATSB also found that the ARTC’s quality assurance processes used during the construction of the crossing loop could be improved. 

Safety priorities

In setting the ATSB’s safety priorities for the coming year, the ATSB has identified the following main risk areas that need ongoing and heightened attention from the Australian transport community:

  • Avoidable aviation accidents—General Aviation (GA) pilots continue to die in accidents that are mostly avoidable. Prominent among these accidents are those that involve low flying, wirestrikes, flying visually into bad weather, mismanagement of partial power loss and poor fuel management.
  • Handling of approach to land—There is a worrying number of cases where stability is not adequately assessed or uncommon manoeuvres are mishandled during an aircraft’s approach to land.
  • Aircraft performance calculations and data input errors—Human error involving incorrect data entry continues to cause concern. In some cases, aircraft systems and operators’ flight management procedures are not catching these errors.
  • Safety in the vicinity of nontowered aerodromes—Non–towered aerodromes continue to pose a risk to aircraft due to poor communication between pilots, ineffective use of see–and–avoid techniques and failure to follow common traffic advisory frequency (CTAF) and other procedures.
  • Robinson R44 fuel tanks—A significant number of R44 helicopters are not fitted with bladder–type fuel tanks and other modifications detailed in manufacturer’s documentation that are designed to provide for improved resistance to post–impact fuel leaks and enhanced survivability prospects in the event of an accident.
  • Reporting of accidents, incidents and transport safety concerns—An ATSB investigation during 2011–12 into under–reporting of wirestrikes revealed that there was around 40 per cent under–reporting of incidents and accidents. While there is a range of factors that could influence under–reporting of this particular occurrence type, it is likely that there is under–reporting of other occurrences, particularly associated with GA operations.
  • Rail safe working irregularities—We continue to draw the attention of track maintenance organisations to the need for adherence to rules and procedures, improved procedures and training and effective communication between train controllers, train crew and track workers.
  • Unsafe marine work practices—we are still seeing risk to life from unsafe work practices in or around ships and loading areas. We will continue to focus on this area to improve the safety of work at sea.

Implementation of the National Rail Safety Reforms

The implementation of the ATSB’s expanded national role in rail transport safety, as agreed in August 2011 under the Intergovernmental Agreement (IGA) on Rail Regulation and Investigation Reform, is on track to begin operation from January 2013. The ATSB, as Australia’s national safety investigator, will assume primary responsibility for rail investigations across Australia as part of a broader national transport reform process. This will shift our workload in the rail mode considerably, as we expect to receive a far greater number of notifications of rail incidents and accidents than at present, and with a greater emphasis on passenger trains.

As implementation progresses we will work collaboratively with our state and territory colleagues to ensure adequate resources are available for the task. This will allow us to develop the capacity to respond quickly and efficiently to safety events as they occur.

Outlook for 2012–13

This year we plan to continue our work across a range of fronts we have spelled out in our annual plan, participating actively in the transport reform agenda, seeking improvements in the efficiency and effectiveness of our investigations, strengthening our relationships with stakeholders and sharing safety information. We continue to ensure that our safety research and data analysis is world class with the aim of identifying and responding to emerging trends in safety.

We will also continue to engage with our neighbours in the region and to be an active and constructive player in the International Civil Aviation Organization and the International Maritime Organization and other international and regional forums that have a role in transport safety. And as always, we must remain alert and prepared for a major accident, testing and improving our preparedness.

During the forthcoming year we will face significant financial constraints as we adapt to the Government’s efficiency dividend and find ways to deliver the high quality expected by the Government and the Australian public within the constraints of the resources made available to us. Our expanding role in the rail sector will require us to work smarter and to allocate resources carefully.

Finally, I must once again thank the investigation and supporting staff of the ATSB whose efforts and expertise consistently enable us to provide our essential safety service to the Australian travelling public.

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