The ATSB Annual Review 2002 documents ATSB's achievements and safety activities from 1 July 2001 to 30 June 2002 and outlines its business planning for 2002-2003. Executive Directors message The Australian Transport Safety Bureau has made significant progress since it began on 1 July 1999 as an operationally independent body within the Commonwealth Department of Transport and Regional Services (DOTARS). During 2001-02, the ATSB assisted the Minister for Transport and Regional Services to develop new legislation that would enable the Bureau to investigate rail accidents on the increasingly…

Boeing 767-238, VH-EAQ EXECUTIVE SUMMARY The left engine of a Boeing 767-238 aircraft (VH-EAQ) failed during the climb phase of a regular passenger transport flight from Melbourne to Sydney. After the failure, which was characterised by a single loud 'bang' and severe vibration, the engine was shut down and the aircraft returned to Melbourne. Engineering inspections of the JT9D-7R4 engine found that one of the fan blades had failed part-way along its length and impacted the fan case at the 11 o'clock position, causing the failure of several nose-cowl bolts and substantial damage to components…

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…

The research paper examined fatal accidents and fatalities involving civil aviation aircraft in Australian airspace between 1990 and 2005. The purpose of the paper was to provide accurate data to industry and the public by identifying key trends and characteristics. Specifically, the objectives of the paper were to: identify trends for fatal accidents and fatalities from 1990 to 2005, examine the number of fatal accidents from 1990 to 2005 by pilot licence type, type of operation, level of proficiency, and aircraft weight, and examine the number of fatalities from 1990 to 2005 by pilot…

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…

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…

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…

Auditory icons caricatures of everyday sounds have the potential to convey information by non-verbal means quickly and accurately. Two experiments investigated the application of auditory icons as warning signals to the civil aviation cockpit environment. Warning signals that are iconic and that stand in a direct relation to the event being signalled, such as the sound of coughing to signal the presence of carbon monoxide, should convey information about the nature of the critical event as well as alerting the operator that there is a problem. By contrast, signals that are arbitrarily…

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…

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…