Following three breakdown of separation occurrences in the airspace of the Sydney Terminal Area (TMA), the Bureau of Air Safety Investigation (BASI) initiated a systemic investigation into the common factors underlying those occurrences. The investigation commenced on 22 June 1998 and was completed by 31 July 1998. Three further occurrences were identified during the course of the investigation. The systemic investigation has identified safety deficiencies primarily related to the management of change, and the rate and complexity of change faced by air traffic controllers operating in the…

This study provides a systematic analysis of the types of human error occurring in Australian civil aviation accidents. It also compares these results against a larger sample of accidents occurring in the United States. Inevitably, all humans make errors. But safety can be enhanced when the number and consequences of these errors are reduced. This paper aims to enhance aviation safety through extending our knowledge of aircrew errors. While the types of accidents and flying operations varied slightly between Australia and the US, the pattern of aircrew errors were remarkably similar. Skill-…

The purpose of this report was to examine the relationship between ageing aircraft and flight safety, to determine the chronological age of the Australian aircraft fleet, and to review current and future directions for the management of ageing aircraft. Age can be managed by retiring the aircraft and purchasing a newer aircraft or through adequately maintaining ageing aircraft through additional and specific maintenance. This requires cooperation between regulators, manufactures, maintainers, operators, and owners. Continuing airworthiness programmes and Supplementary Inspection Programmes…

Maintenance incidents contribute to a significant proportion of worldwide commercial jet accidents, yet until recently, little was known of the nature of maintenance incidents and the factors which promote them. In face-to-face interviews, maintenance technicians were asked to report examples of maintenance incidents which they had experienced first-hand. Eighty-six incident reports were recorded. Human factors were involved in most of the reported incidents, with workers on duty between the hours of 0200 and 0400 having a greater chance of having an incident than workers on duty at other…

The details of 75 fatal aeroplane accidents were extracted from the BASI database. The largest proportion (36%) of the accidents occurred on private/business flights. The three most frequent first occurrences in accidents were loss of control; collision with terrain (control unknown); and wirestrike. Most accidents had more than one contributing factor. Over 70% of the accidents involved pilot factors. The most common pilot factors related to poor judgement and decision making. In recent years, BASI has recognised that while pilot factors are of great importance, accidents frequently have…

A review of existing Commonwealth, State and Territory legislation relating to the transport of dangerous goods by rail, was undertaken. The review provides an overview of the status, coverage and adequacy of existing rail dangerous goods transport legislation. The review also examines options for the development of a nationally uniform regulatory regime for rail dangerous goods transport operations. Issues relating to inter-modal harmony with the road transport sector, and legislative options to achieve uniformity are also discussed. The review concludes that a nationally uniform rail…

The ATSB has come a long way since its creation on 1 July 1999. Legislation, training and IT systems have all been upgraded. The ATSB has an increasingly national and international reputation for independent safety material. This is reflected in the almost 800,000 new visitors to the ATSB website which also had more than 30 million 'hits' in 200607, and in multiple articles in such publications as the prestigious US-based Flight Safety Foundations AeroSafety World. During 2006 - 07, the ATSB finalised its complex investigation into Australian civil aviation's worst accident since 1968, the 15…

Human error is recognised as an important issue in fields as diverse as medicine, mining and shipping, and to some extent aviation. Although the human element has long been recognised as important in the cockpit, its role in aircraft maintenance has been largely overlooked. According to Boeing figures 12% of major aircraft accidents involve maintenance, and 50% of flight delays in the US are caused by maintenance errors. In response to a worldwide lack of information on the issue, in late 1998 the Bureau distributed a safety survey to all licensed aircraft maintenance engineers in Australia.…

Since 1970 fatalities resulting from accidents between road vehicles and trains at level crossings have reduced by about 70 per cent. However, recently there has been an increasing number of accidents involving heavy road vehicles. Between April 2006 and December 2007 the ATSB investigated 12 level crossing accidents. Of these 12 accidents, nine have involved heavy road vehicles, four of which have been collisions with long distance passenger trains. In addition, during the same period State authorities have investigated a further three significant accidents between heavy vehicles and…

This report provides aviation accident and incident, collectively termed occurrence, data for the period 1 January 1998 to 30 September 2008. This data was provided to the Australian Transport Safety Bureau by 'responsible persons' as defined in the Transport Safety Investigation Regulations 2003, Part 2.5. The data excludes non-VH registered operations in the sport aviation category, and is current as at 30 September 2008. The data will be adjusted quarterly to reflect new information received during the reporting period.