In the 2010-2011 financial year, the Australian Transport Safety Bureau (ATSB) completed 51 aviation, 11 marine, and 8 rail investigations where safety factors (events or conditions affecting safety risk) were identified using the ATSB analysis framework. From these investigations, 121 safety issues (factors that have a potential to adversely affect the safety of future operations) were identified and 137 safety actions were undertaken by various parties to address these safety issues. This report documents and analyses these safety issues and safety actions and explores the risk levels (…

The summary reports detailed herein were compiled from information provided to the ATSB by individuals or organisations involved in an accident or serious incident investigation completed between the period 1 July 2011 and 30 September 2011.

This bulletin presents a collection of short aviation investigation reports recently completed by the ATSB. These reports are based on information provided to the ATSB by individuals or organisations involved in an accident or serious incident.

Safe flight depends on reliable power. Despite the money and effort spent on ensuring aircraft engines are reliable, equally reliable systems are needed to ensure that engines always get the fuel they need. This report discusses procedures that pilots can use before and during a flight to help them be absolutely sure they will have sufficient fuel to land at their destination aerodrome with reserve fuel intact. It does not discuss procedures to ensure fuel quality, such as checking all fuel drain valves for contaminants or using approved fuel, although these remain…

Review by the Chief Commissioner This Annual Report covers the second year of operation of the Australian Transport Safety Bureau (ATSB) as an independent statutory agency. It has been a year of consolidation in how we conduct transport safety investigations, matched by expansion in our safety research, analysis and education functions. In both areas we have increased our capacity to bring about improvements in transport safety. A key element of consolidation is our progressive clearing of what was becoming a backlog of incomplete larger investigations. This was most noticeable in aviation,…

The first persons arriving at a railway accident site can render valuable assistance to minimise injury and loss of life, reduce property loss through damage, and prevent loss of clues and evidence that can identify the factors that contributed to the accident. Often police and emergency services and representatives of the railway network owner and/or railway operator are the first trained personnel to arrive at railway accident sites. In addition, supervisory officers coordinate response and recovery from locations off-site. these guidelines have been prepared by the ATSB to assist these…

The ATSB often receives reports from pilots that another aircraft is flying too close to them in uncontrolled airspace. Not surprisingly, three quarters of these reports involve aircraft within 10 NM from a non-towered aerodrome. It is difficult for pilots to spot another aircraft through visual observations alone. There are twice as many near-collision notifications where pilots had no prior warning of other aircraft in their vicinity, compared with situations when a pilot received an alert by radio, or via traffic avoidance system like TCAS. Supplementing your visual lookout with radio and…

Introduction 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. In the 5 years 2006–2010, there were 72 occurrences of visual flight rules (VFR) pilots flying in instrument meteorological conditions (IMC) reported to the ATSB. Seven of these resulted in fatal accidents, causing 14 fatalities. That is, about one in ten VFR into IMC events result in a fatal outcome. Flying into IMC can occur in any phase of flight. However, a…

Since 1984, the Australian Transport Safety Bureau and the former Bureau of Air Safety Investigation have produced numerous aviation research and education reports. This brochure lists those reports in chronological order and arranged by the broad topic area. All reports are available electronically on the ATSB internet site.

There were a total of 546 marine occurrences reported to the Australian Transport Safety Bureau from 2005 to 2010. There were significant decreases in reported occurrences in 2008 and 2010; however, the number of serious incidents remained fairly constant for the duration of the period. The number of accidents has decreased from eight each year from 2005 to 2007 to three each year from 2008 to 2010, which reflects the decrease in fatal accidents and people missing during the second half of the period. Injuries sustained were mainly to one person in each occurrence; however, there were…