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…

Weather-related general aviation accidents remain one of the most significant causes for concern in aviation safety; the often-fatal outcomes of these accidents are usually all the more tragic because they are avoidable. The dangers of visual flight rules (VFR) pilots flying into instrument meteorological conditions (IMC) have been recognised for a very long time, yet VFR pilots still fly into deteriorating weather and IMC. In the decade from 1 July 2009 to 30 June 2019, 101 VFR into IMC occurrences in Australian airspace were reported to the ATSB. Of…

Introduction This guideline has been prepared by the Australian Transport Safety Bureau (ATSB) to: Outline the role and responsibilities of the ATSB. Detail required actions by an aerodrome operator in the event of an aviation accident. Outline possible actions by the ATSB to investigate an aviation accident. Your Aerodrome Emergency Plan should include reporting an aircraft accident to the ATSB as part of the standard response to the accident. Who is the ATSB? The ATSB is an independent Commonwealth Government statutory agency governed by a Commission…

View on Australian Government Transparency Portal The ATSB Annual Report 2018–19 outlines performance against the outcome and program structure in the Infrastructure, Regional Development and Cities Portfolio Budget Statements 2018–19. In 2018–19, the ATSB continued to make a significant contribution to transport safety in Australia, thanks to the release of several substantial and high-profile investigation reports which contained valuable safety learnings for the aviation, rail and marine transport modes. During the year, we also entered into a strategic partnership with the Royal…

Accident experience has provided substantial evidence that the use of upper torso restraints reduces the risk of serious injuries to the head, neck, and upper torso of aircraft occupants, and they reduce the rate of fatalities for occupants involved in otherwise survivable aircraft accidents. What happened On 10 January 2017 a Cessna 172M, registered VH‑WTQ, departed Agnes Water aeroplane landing area (ALA), Queensland on a passenger charter flight to a beach ALA on Middle Island. While the pilot was conducting an airborne inspection of the beach, at a height of about 60 ft, the aircraft had…

Introduction As the accountable authority of the Australian Transport Safety Bureau (ATSB), I am pleased to present the ATSB’s Corporate Plan for 2015–16, which covers the period 2015–16 to 2018–19. This Corporate Plan sets out the ATSB’s purpose, its strategies for achieving that purpose and how the effect of the strategies and the attainment of the ATSB’s purpose will be measured. It has been prepared in accordance with paragraph 35(1)(b) of the Public Governance, Performance and Accountability Act 2013. The Plan takes account of the relevant provisions of the Transport Safety Investigation…

As the accountable authority for the Australian Transport Safety Bureau (ATSB), I am pleased to present the ATSB’s 2016–17 Corporate Plan, which covers the period 2016–17 to 2019–20. This Corporate Plan sets out the ATSB’s purpose, its strategies for achieving that purpose and how the effect of the strategies and the attainment of the ATSB’s purpose will be measured. It has been prepared consistent with paragraph 35(1)(b) of the Public Governance, Performance and Accountability Act 2013. The Plan takes account of the relevant provisions of the Transport Safety Investigation Act 2003 (the TSI…