A number of changes have been made to this document since it was first published in May 2011. The number of occurrences reported have remained the same, and only the rates of occurrences per departure or hours flown have changed. See page vi of AR-2011-020 for further details. In 2010, uncontained engine failures occurred on two high-capacity aircraft (a Boeing 747 and an Airbus A380); two air transport aircraft almost collided in non-controlled airspace, coming within 40 metres of each other; and a cockpit window blew out of a Metro aircraft at about 20,000 feet, resulting in a rapid cabin…

Coronial investigations and inquests are different to ATSB safety investigations, with different objectives and evidentiary requirements. It is important that the ATSB works closely with coronial officers and the police as early as possible in an investigation. While ATSB investigations and coronial inquests are separate processes, they share a similar important objective: to prevent a similar death occurring in the future. This page outlines how the ATSB can work in parallel with coronial officers and the police. It also explains the ATSB's legal limitations on releasing evidence from an…

Wirestrikes pose an on-going problem to aerial agricultural operations. There are 180 wirestrike accidents in the Australian Transport Safety Bureau (ATSB) database for the period between 2001 and 2010. Of these, 100 involved agricultural flying. Research by the ATSB has shown that 63 per cent of pilots were aware of the position of the wire before they struck it. This publication describes recent aerial agricultural wirestrike accidents. In all these cases, the aircraft struck a powerline that was known to the pilot. In many of these accidents, the…

Introduction This ATSB booklet aims to increase awareness among flying instructors and pilots of the issues relating to partial power loss after take-off in single-engine aircraft. Accident investigations have shown that a significant number of occurrences result in fatalities or serious injury due to the aircraft stalling and subsequent loss of control resulting in a collision with the ground or water. Historically, the simulated total loss of power and subsequent practice forced landing has been the core of a pilot’s emergency training. The data,…

General Aviation pilots (particularly agricultural pilots) continue to strike wires, such as powerlines, while flying. Over the past 10 years, there were around 180 wirestrike accidents in Australia. In the majority of these accidents the pilots were aware of the powerlines before they struck them. Minimise your risk The following strategies will help minimise the risk of striking wires while flying: Ensure you are physically and mentally fit to fly. Fatigue can adversely affect short-term memory, reaction time, alertness levels and your focus of attention. Set client expectations so that…

Partial engine power loss is when the engine provides less power than commanded by the pilot, but more power than idle thrust. This kind of power loss is more complex than a complete failure, and it can be much harder to stay ahead of the aircraft. The pilot is thrust into a situation where the engine is still providing some power; however, the power may be unreliable, and the reliability may be difficult to assess. As a result, pilots are uncertain about the capabilities of their aircraft, and what their options are-a situation that has led to loss of aircraft control at heights close to the…

The Human Factors Analysis and Classification System (HFACS) is a hierarchical taxonomy that describes the human factors that contribute to an aviation accident or incident that is based on a chain of- events theory of accident causation and was derived from Reason's (1990) accident model. The objectives of this exploratory study were to identify relationships between the factors of the HFACS taxonomy and to assess the usefulness of HFACS as a predictive tool. The associations found in this study may assist investigators in looking for associated factors when contributing factors are found.…

This report documents the number and types of safety occurrences involving loading of high capacity aircraft across a 7-year period to raise awareness within the aviation industry of the associated issues. Incorrect loading of containers, pallets or bags into aircraft can result in them being outside of weight or centre of gravity operating limits, and this may influence aircraft controllability. Most high capacity aircraft loading occurrences are relatively minor, with cargo locks not being raised being the most common. More serious occurrences have involved shifting cargo and unlisted cargo…

This report tables rail safety occurrence data by state and territory between 1 January 2001 and 31 December 2010. Data is adjusted biannually to reflect new information that comes to light during the reporting period. There is a lag period of approximately 3 to 4 months between the end of the 6-monthly reporting period and publication of this data. The data is presented as counts, and normalised using kilometres travelled and number of track kilometres. Data presented in this report conforms to ON-S1: Occurrence Notification Standard 1 (2004) and OC-G1: Occurrence Classification…

The ATSB receives around 15,000 notifications of aviation occurrences each year; 8,000 of which are accidents, serious incidents and incidents. It is from the information provided in these notifications that the ATSB makes a decision on whether or not to investigate. While further information is sought in some cases to assist in making those decisions, resource constraints dictate that a significant amount of professional judgement needs to be exercised. There are times when more detailed information about the circumstances of the occurrence would have allowed the ATSB to make a more informed…