Boeing 747-438, VH-OJJ EXECUTIVE SUMMARY On 24 April 2001, a Boeing 747-400, VH-OJJ, experienced the loss of both left and right combustion fairing panels from the number three engine during take-off on a flight from Sydney to Los Angeles. The fairing panels were ejected forcefully from the bypass duct of the engine, causing minor localised damage to the duct internal surfaces and the trailing edge of the centre wing flap section. Examination by the Technical Analysis unit showed the damage to be consistent with fairing mis-installation, whereby the hooks on the right panel were not engaged…

EXECUTIVE SUMMARY This report follows a previous report published by the Australian Transport Safety Bureau (ATSB) in 2003 on airspace-related occurrences titled Airspace-Related Occurrences Involving Regular Public Transport and Charter Aircraft within Mandatory Broadcast Zones. The 2003 report provided a detailed examination of the ATSB's accident and incident data for airspace-related occurrences in Mandatory Broadcast Zones (MBZs), between 1994 and 2001. In recognition of changes in traffic levels, occurrence reporting rates and the classification of incidents following the enactment of…

Following the grounding of large numbers of piston-engine aircraft across eastern Australia in early January 2000 as a consequence of using contaminated aviation gasoline (Avgas), the Australian Transport Safety Bureau initiated a major safety deficiency investigation into the circumstances of the contamination. Guidance for the investigation was subsequently provided in the form of Terms of Reference, which stated that the investigation was being widened to examine the following: the existing standards for aviation gasoline; the details of risk analyses undertaken prior to and during the…

In June 2006, the ATSB released an aviation research investigation report titled Wire-strike Accidents in General Aviation: Data Analysis 1994 to 2004. Since the publication of this report the ATSB has received additional information from key industry stakeholders. As a result, the ATSB has made some revisions to the report to incorporate this advice. Furthermore, a discrepancy was also identified in one of the tables, which has since been updated. Accordingly, the information contained in the report may differ slightly from that contained in the initial report. Wire strikes are a significant…

The purpose of this publication is to provide an overview of level crossing accident fatalities in Australia. The information provided is based on unpublished data obtained from the Australian Bureau of Statistics but responsibility for the analyses presented here rests solely with the ATSB.

Aircraft maintenance errors are estimated to be involved in 12% of airline accidents worldwide. Records maintained by the Australian Transport Safety Bureau (ATSB) indicate that 4.5% of Australian aircraft accidents involve maintenance deficiencies. Human error in aircraft maintenance is poorly understood and has not been the subject of previous studies in Australia. In late 1998 the Bureau of Air Safety Investigation (now ATSB) distributed a survey to Licensed Aircraft Maintenance Engineers (LAMEs) in Australia. The survey was designed to identify safety issues in maintenance, with a…

This paper provides a preliminary review of options for making marine pilot transfers safer, as the traditional method of transferring via a pilot ladder has resulted in fatalities and serious injuries. The project included a review of the literature, interviews with pilots and a survey of methods used in other industries for similar tasks. Results indicate that the safety of the current transfer arrangement would be increased through strategies including ladder design improvements, use of fall protection systems and/or use of mechanical personnel elevation systems. Each of these strategies…

While improper execution of the flare manoeuvre has been implicated in many landing incidents, very few human factors studies appear to have examined this problem. Our flight simulation study examined three different visual strategies that pilots could use to time the flare. On each trial, non-pilots, student pilots or private pilots were required to judge either: (i) their time-to-contact with the ground; or (ii) an idealised time to initiate the flare. Our data provided some support for the hypothesis that pilots initiate the flare when their perceived time-to-contact with the ground…

The primary aim of this study was the development of a set of normative data that captured the performance of a sample of general aviation pilots during a simulated flight from Wagga Wagga to Bankstown via Canberra, Goulburn and Mittagong. A secondary aim was to consider the impact of pilot qualification on the performance of pilots during the five legs of the flight. Pilots were issued a completed flight plan and all the relevant documents necessary to complete the flight, including weather information, maps, and an aircraft checklist. A total of 34 pilots were recruited to undertake the…

The aim of this study was to investigate the feasibility of forensic DNA-based techniques in identifying species involved in Australian aviation bird strikes. Experimental bird tissues were subjected to severely damaging conditions to determine if DNA could be extracted from these samples. In addition, DNA and feather microscopy databanks were created from the species classified as being the highest risk for strikes to provide reference data to compare against unknown samples. Finally, a DNA sampling kit was created and distributed widely to aerodromes across Australia for collection of…