The ATSB Annual Report 2020–21 outlines performance against the outcome and program structure in the Department of Infrastructure, Transport, Regional Development and Communications Portfolio Budget Statements 2020–21.  View on Australian Government Transparency portal Chief Commissioner's review 2020–21 I am pleased to deliver this annual report for the Australian Transport Safety Bureau (ATSB), my first as Chief Commissioner and Chief Executive Officer. While continuing to navigate the challenges of the COVID-19 pandemic, 2020–21 saw the ATSB commence, progress and complete a series…

Safety Advisory Notice To owners and maintainers of Stolp Acroduster SA-700/750 aircraft Stolp Acroduster upper-wing attachment point, eye bolt fatigue cracking resulted in an in-flight break-up. What happened On 18 August 2021, an amateur-built Stolp Acroduster II SA-750, registered VH-YEL, departed Caboolture Airfield, Queensland, Australia for an aerobatic flight, with the pilot being the sole occupant. A short time later the aircraft sustained an in-flight break-up. The aircraft was destroyed and the pilot was fatally injured. Why did it happen The centre section…

Operating an amateur-built experimental helicopter outside the recommended design intent can potentially expose the helicopter to unintended stresses, and lead to the failure of critical components in-flight. What happened On 28 July 2015, the pilot and owner of an amateur-built Cicaré CH-7BT helicopter, registered VH‍-JEW, was conducting a ferry flight from Indee Station to Roy Hill Station, Western Australia. When about 8.5 NM north‑east of Roy Hill Station, the stabiliser assembly fractured leading to an in-flight break up and collision with terrain. The pilot was fatally injured and the…

Safety Advisory Notice The ATSB advises helicopter operators involved in hoist operations that improper stowage of the rescue hoist hook assembly can lead to excessive movement and accelerated wear of the wire rope. If undetected, the wear and associated damage can significantly reduce the cable integrity and operational safety of the hoist system. Should the cable fail while under load during operation, personnel being winched may sustain serious or fatal injuries. Rescue hoist and hook assembly Source: NSW Parks and Wildlife Service What happened On 4 February 2020, an Airbus Helicopters…

The purpose of this report Each year, thousands of safety occurrences involving Australian aircraft and foreign‑registered aircraft operating in Australia are reported to the Australian Transport Safety Bureau (ATSB). This report is part of a series that aims to provide information and statistical data to the aviation industry, manufacturers and policy makers, as well as to the travelling and general public, about these aviation safety occurrences. In particular, the data can be used to determine what can be learned to improve transport safety in the aviation sector. The study uses…

Safety Summary Why the ATSB undertook this research On 6 April 2020, the Royal Commission into National Natural Disaster Arrangements (RCNDA) issued a notice to give information to the ATSB. Within this notice, was the requirement to ‘describe any key operational and safety challenges encountered in coordinating and responding to fires associated with the use of aircraft and aerial fire fighting techniques’. This statistical report forms part of the ATSB’s response to the Royal Commission’s notice to give information. In addition, since 2018 the ATSB has commenced six investigations involving…

Safety Advisory Notice The ATSB advises all commercial balloon operators utilising vehicle‑assisted deflation to review their current operational practices with the aim of mitigating the safety risks associated with the procedure. What happened On 16 March 2019, two passengers were seriously injured when the basket of a Kavanagh B‑400 hot‑air balloon tipped over during vehicle-assisted deflation. Prior to the accident, the balloon, operated as a scenic charter flight, landed without incident at a private property near Coldstream, Victoria. Due to a lack of wind and the large size of the…

The primary mechanism for the prevention of carbon monoxide exposure to aircraft occupants is to carry out regular inspections of piston-engine exhaust systems to identify and repair holes and cracks, and to detect breaches in the firewall between the engine compartment and the cabin. 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…

Executive summary The air traffic control safety net fails when human errors go undetected and uncorrected. These operational errors are generally more likely to occur in circumstances such as very high or very low workload situations, or events involving complex coordination. Predisposing or underlying factors relating to the ATC operational environment can influence the frequency, and the consequences, of operational errors. System safety can be improved by the identification and rectification of these predisposing factors. Information from air traffic controllers from each sector within…

As the accountable authority for the Australian Transport Safety Bureau (ATSB), I am pleased to present the ATSB’s 2018–19 Corporate Plan, which covers the period 2018–19 to 2021–22. This Corporate Plan sets out the ATSB’s purpose – to improve transport safety – and its strategies for achieving that purpose. The Plan also sets out the ATSB’s key deliverables and associated performance criteria. It 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…