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…

Everyday errors such as incorrectly transcribing or inadvertently dialling a wrong telephone number normally have minimal consequences. For high-capacity aircraft operation, the consequence of such errors can be significant. There have been numerous take-off accidents worldwide that were the result of a simple data calculation or entry error by the flight crew. This report documents 20 international and 11 Australian accidents and incidents (occurrences) identified between 1 January 1989 and 30 June 2009 where the calculation and entry of erroneous take-off performance parameters, such as…

In the 2009-2010 financial year, the Australian Transport Safety Bureau (ATSB) completed 37 aviation, 10 marine, and 11 rail investigations where safety factors were identified using the ATSB analysis framework. From these investigations, 124 safety issues (factors that have a potential to adversely affect the safety of future operations) were identified and 141 safety actions were undertaken to address these safety issues. This report documents and analyses these safety issues and safety actions and explores the risk levels assigned to provide an understanding of where the greatest risks to…

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…

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…

Review by the Chief Commissioner The Australian Transport Safety Bureau (ATSB) became a separate statutory agency on 1 July 2009. This was the final step in the transition to independence from being an operational division of the Department of Infrastructure, Transport, Regional Development and Local Government. This Annual Report covers the first year of operations under those new arrangements. Operational start‑up for the new organisation was smooth and well‑controlled, thanks in large part to the hard work of our corporate services staff and our colleagues in the Infrastructure Department…

In April 1999 the Australian Transport Council (ATC) agreed to the establishment of an independent review of rail safety arrangements in Australia, focusing particularly on the interstate system. A Standing Committee on Transport (SCOT) steering committee, comprising industry and government representatives, developed the review brief and supervised the conduct of the review by consultants Booz-Allen & Hamilton. The report was finalised in September 1999. ATC Ministers considered the report at their meeting of 12 November 1999, and agreed that: the report's main recommendation of two new…

With the intensity of agricultural related aviation activity increasing at this time of the year with activities such as locust spotting and spraying, it is important that all aerial work pilots maintain an awareness of the fatal consequences of fatigue while carrying out these activities. The ATSB was recently notified of an incident where a pilot undertaking locust spotting activities needed to be woken by an observer on the aircraft. The pilot reportedly flew part-time, and his fatigue may have been related to his other activities as a farmer. Not only is fatigue brought on by the amount…