In the 2009-2010 financial year, the Australian Transport Safety Bureau (ATSB) completed 37 aviation, 10 marine, and 11 rail investigations where safety factors were identified using the ATSB analysis framework. From these investigations, 124 safety issues (factors that have a potential to adversely affect the safety of future operations) were identified and 141 safety actions were undertaken to address these safety issues. This report documents and analyses these safety issues and safety actions and explores the risk levels assigned to provide an understanding of where the greatest risks to…

Everyday errors such as incorrectly transcribing or inadvertently dialling a wrong telephone number normally have minimal consequences. For high-capacity aircraft operation, the consequence of such errors can be significant. There have been numerous take-off accidents worldwide that were the result of a simple data calculation or entry error by the flight crew. This report documents 20 international and 11 Australian accidents and incidents (occurrences) identified between 1 January 1989 and 30 June 2009 where the calculation and entry of erroneous take-off performance parameters, such as…

The ATSB receives around 15,000 notifications of aviation occurrences each year; 8,000 of which are accidents, serious incidents and incidents. It is from the information provided in these notifications that the ATSB makes a decision on whether or not to investigate. While further information is sought in some cases to assist in making those decisions, resource constraints dictate that a significant amount of professional judgement needs to be exercised. There are times when more detailed information about the circumstances of the occurrence would have allowed the ATSB to make a more informed…

One passenger was fatally injured when a helicopter crashed in bad weather near Cairns last year. At 1130 on 12 March 1999 the Bell 206L-3 helicopter departed from Green Island on a routine passenger charter flight to Cairns airport. The helicopter took off in light drizzle and the pilot elected to track back to The Pier via the shipping channel. The Bureau of Meteorology had issued an amended aerodrome forecast for Cairns at 0808 for the 24-hour period from 1000. It forecast an easterly wind at 15 knots, visibility of 9,000 metres and light rain. Some cloud patches were expected with a base…

Every pilot's worst nightmare is the thought of a collision with another aircraft. History shows that it can be just as catastrophic on the ground as in the air. The industry's worst disaster remains the collision between two Boeing 747s on the runway at Tenerife in 1977, in which 583 people died. According to the Federal Aviation Administration, the number one aviation safety issue in the United States is now runway incursions, which are occurring at a rate of about 230 a year. In Australia the figures are a lot lower. The ATSB recorded a total of 89 runway incursions in 1996, 130 in 1998,…

In April 1999 the Australian Transport Council (ATC) agreed to the establishment of an independent review of rail safety arrangements in Australia, focusing particularly on the interstate system. A Standing Committee on Transport (SCOT) steering committee, comprising industry and government representatives, developed the review brief and supervised the conduct of the review by consultants Booz-Allen & Hamilton. The report was finalised in September 1999. ATC Ministers considered the report at their meeting of 12 November 1999, and agreed that: the report's main recommendation of two new…

This report tables rail safety occurrence data by state and territory between 1 January 2001 and 30 June 2010. Data is adjusted biannually to reflect new information that comes to light during the reporting period. There is a lag period of approximately 3 to 4 months between the end of the 6-monthly reporting period and publication of this data. The data is presented as counts, and normalised using kilometres travelled and number of track kilometres. Data presented in this report conforms to ON-S1: Occurrence Notification Standard 1 (2004) and OC-G1: Occurrence Classification Guideline 1 (…

Most aerodromes in Australia are located in uncontrolled airspace and do not have an air traffic control presence. At these non-towered aerodromes, and in the vicinity of them, pilots are responsible for making themselves aware of nearby aircraft and maintaining separation. This report aims to give pilots an appreciation of the types of safety events that have been associated with operations at non-towered aerodromes and provide education on expected behaviours to assist pilots in being prepared for the risks. Generally, operations at non-towered aerodromes can be considered to be safe, but…

Summary Most aerodromes in Australia are located in uncontrolled airspace and consequently do not have an air traffic control presence. At and around non-controlled aerodromes, pilots are responsible for making themselves aware of nearby aircraft and maintaining separation. This report aims to provide pilots with an appreciation of the types of safety events that are associated with operations at non-controlled aerodromes and provide education on expected behaviours to assist pilots in being prepared for the risks.  Generally, operations at non-towered aerodromes can be considered to be…

Review by the Chief Commissioner The Australian Transport Safety Bureau (ATSB) became a separate statutory agency on 1 July 2009. This was the final step in the transition to independence from being an operational division of the Department of Infrastructure, Transport, Regional Development and Local Government. This Annual Report covers the first year of operations under those new arrangements. Operational start‑up for the new organisation was smooth and well‑controlled, thanks in large part to the hard work of our corporate services staff and our colleagues in the Infrastructure Department…