Safety Advisory Notice To Rollingstock Operators Number: RO-2020-022-SAN-002 Unknown functions in locomotive braking systems An ongoing investigation, conducted by NSW’s Office of Transport Safety Investigations on behalf of the Australian Transport Safety Bureau, highlights risks associated with misunderstood functionality of locomotive braking systems. Locomotive drivers require a clear understanding of the braking systems on all the locomotives they are operating. What happened On 15 December 2020 a loaded grain train derailed whilst descending…

Safety Advisory Notice Loss of drive to the main rotor system What happened On 14 February 2022, the pilot of a Garlick Helicopters UH-1H was providing aerial firefighting support to combat the ‘Labrina’ bushfire that had developed north of Launceston, Tasmania. That afternoon, the pilot was tasked to firebomb a localised hot-spot that had developed within the fireground. Witnesses both on the ground, and within a nearby helicopter, observed the early release of the water load from the underslung bucket, before the UH-1H commenced a left turn and descended toward nearby open…

Safety Advisory Notice To aerobatic pilots and instructors All aircraft types do not spin and recover in the same way. Know your aeroplane type, what recovery techniques will work and what recovery techniques will not work. What happened On 23 June 2021, while conducting spin entry and recovery training from 5,800 ft above ground level, the Cessna A150M Aerobat did not fully recover from a spin to the left before impacting terrain. Factors uncovered during the investigation The aerobatics instructor was experienced in conducting spins, primarily in the Pitts Special aircraft type…

I am pleased to present the Australian Transport Safety Bureau’s (ATSB) Corporate Plan, which covers the period 2020-2021 to 2023-24. This version of the Corporate Plan, issued in March 2021, is a minor variation of the original plan. I acknowledge this is a time of great uncertainty for the transport industry in general, and aviation in particular. Many ATSB investigators and operational support staff have come from the aviation, rail and marine transport modes and continue to maintain strong industry links. We have great empathy for operators and their respective workforces who are facing…

Carbon monoxide (CO) is a colourless, odourless and tasteless gas found in the exhaust gases of piston‑engine aircraft. Carbon monoxide detectors provide warning to aircraft occupants of the presence of CO levels in the cabin that are above safe concentrations. What happened On the afternoon of 31 December 2017, the pilot and five passengers of a DHC-2 Beaver floatplane, registered VH-NOO, boarded the aircraft for a charter flight from Cottage Point to Rose Bay, New South Wales. The aircraft taxied for about 7 minutes. Shortly after take-off, the aircraft deviated from the standard flight…

View on Australian Government Transparency Portal The ATSB Annual Report 2019–20 outlines performance against the outcome and program structure in the Infrastructure, Regional Development and Cities Portfolio Budget Statements 2019–20. In a time of great uncertainty due to the COVID-19 global pandemic, I am proud to report that in 2019–20 the Australian Transport Safety Bureau (ATSB) has been able to continue our focus on improving transport safety through the independent investigation of accidents and incidents, with minimal impact on our productivity and performance. With many ATSB…

Safety summary Update This statistical report shows aviation occurrence and activity data over the 10-year period from 2010–2019 to provide an insight into current and possible future trends in aviation safety. The previous edition (AR‑2020‑014) published in April 2020 presented 10 years of occurrence data, but aviation activity data was only available for 2014–2018 as 2019 activity data was not available at the time of publishing. This report is an update of the previous edition with the addition 2019 aviation activity data which also allows all occurrence rates to be presented for the…

Safety Advisory Notice Yakovlev Aircraft Factories Yak-52 owners and maintainers Elevator bellcranks manufactured from aluminium alloy, fitted to Yakovlev Aircraft Factories Yak-52 aircraft, are known to crack. Periodic inspections are important for detecting the presence of fatigue cracking early and ultimately preventing the failure of the component in-flight. What happened On 5 June 2019, the pilot and passenger of a Yakovlev Aircraft Factories Yak-52 aircraft, departed Southport airfield, Queensland, for a private aerobatic flight. During the flight, the aircraft collided with water…

Safety Advisory Notice To R44 helicopter operators Fatigue cracking in an R44 helicopter clutch shaft resulted in the total loss of drive to the main rotor system while airborne. What happened On the morning of 22 December 2020, the pilot of a Robinson R44 helicopter was conducting aerial agricultural spray operations on a property 13 km south‑east of Clare Valley Aerodrome, South Australia. After completing numerous spray runs throughout the morning, the pilot was preparing to land the helicopter adjacent to a loading vehicle for replenishment of…

I am pleased to present the Australian Transport Safety Bureau’s (ATSB) Corporate Plan, which covers the period 2021-22 to 2024-25. This Corporate Plan has been prepared consistent with paragraph 35(1)(b) of the Public Governance, Performance and Accountability Act 2013 and the relevant provisions of the Transport Safety Investigation Act 2003 (the TSI Act), which establishes the ATSB. The Corporate Plan is also consistent with the Minister’s revised Statement of Expectations 2021–23 (SOE) for the ATSB, as notified under Section 12AE of the TSI Act. The SOE sets out clear…