On 3 July 2009, the Australian Transport Safety Bureau (ATSB) was notified that a SAAB Aircraft Company 340B (SAAB), registered VH-ZLW, had commenced its take-off roll along the runway 25 left edge lights at Sydney Kingsford Smith Airport, New South Wales. This was one of three occurrences over the previous 2 years that involved aircraft commencing take-off on the runway edge lighting. In addition, within the previous 2 years the ATSB investigated two other occurrences involving pilot misidentification of runway alignment cues or lack of those cues during take-off. All five Australian…

This report provides Australian aviation accident and incident, collectively termed occurrence, data for the period 1 January 1999 to 31 March 2009. 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 (except for Tables 1 and 2 which shows all occurrences), and is current as at 31 March 2009. The data will be adjusted quarterly to reflect new information received during the reporting period.

This report tables rail safety occurrence data by state and territory between 1 January 2001 and 30 June 2009. 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 Guideline…

This publication celebrates the ten-year anniversary of the formation of the Australian Transport Safety Bureau (ATSB) on 1 July 1999. It is the story of the ATSB, and the earlier organisations that came together to form the ATSB a decade ago. A proud history The ATSB was formed on 1 July 1999 from the amalgamation of the Bureau of Air Safety Investigation (BASI), the Marine Incident Investigation Unit (MIIU), and non-regulatory parts of the Federal Office of Road Safety (FORS). In addition, an embryonic Rail Safety investigation capability was established. As this publication shows, each of…

This publication represents the last in a series of annual reviews, dating back to 1999-2000. Over the last ten years, the Bureau has built a reputation as a world class investigative organisation. This has been chronicled through the ten annual reviews which the ATSB has released. From 1 July 2009, the ATSB has taken on new annual reporting responsibilities which will result in the publication of a very different document. This change is entirely appropriate given the ATSB's status as a newly established statutory agency. However, consistent with our new mandate, I know the Commission will…

Although several studies have reported the common threats and errors identified in line operations safety audits (LOSAs) of high capacity regular public transport (RPT) operations (Klinect, Wilhelm & Helmreich, 1999; Veilette, 2005; Thomas, 2004), there is little information on the types of threats and errors faced by pilots in other parts of the aviation industry. This report catalogues the most common threats to operations, and errors made by pilots, in aerial work and low capacity air transport operations, as perceived by flight instructors, check-and-training pilots, chief pilots and…

On the early evening of 31 January 2001 at Melbourne International Airport, Boeing 777-300 A6-EMM aborted its take-off run at low speed as a result of a failure within the left (No.1) engine. Although the failure was associated with a large compressor surge within the engine, no subsequent fire developed and the aircraft was able to safely return to the terminal building on its remaining serviceable engine. Failure of the RB211 Trent 892 engine as fitted to the aircraft was a result of the release of a single blade from the low-pressure compressor (fan) rotor disk. The blade release caused…

Introduction This publication is the first in a pilot education series by the Australian Transport Safety Bureau (ATSB) on avoidable accidents. In this report, we will focus on accidents involving unnecessary and unauthorised low flying; that is, flying lower than 1,000 ft (for a populous area) or 500 ft (for any other area) above ground level without approval from the Civil Aviation Safety Authority (CASA). Between 1999 and 2008, there were 147 fatal accidents reported to the ATSB involving aerial work, flying training, private, business, sport and…

This information paper reviews the Bureau's policy on testing for drugs and alcohol, attempts to assess the prevalence of drugs and alcohol in aviation accidents and incidents, and discusses the adequacy of the present policy. The policies of Canada, the United Kingdom, and the United States are also outlined.

This report was commissioned by the Bureau of Air Safety Investigation (BASI) to investigate the system of Notices to Airmen (NOTAM) following statements from some airline flight crews that current NOTAM presentation is not optimised to meet their needs. Pilots had stated that: Some NOTAM are not clearly written, The NOTAM format can be difficult to decipher, There is too much irrelevant information provided.