Annual Report

Introduction

The ATSB 2013–14 Annual Report outlines performance against the outcome and program structure in the 2013–14 Infrastructure and Transport Portfolio Budget Statements. 

Chief Commissioner’s review 2013–14

2013–14 was the ATSB’s fifth year in its current form as a fully independent agency within the Infrastructure and Regional Development portfolio. I am honoured that the Deputy Prime Minister has appointed me to continue as Chief Commissioner for the next two years, which I take as a strong vote of confidence in the organisation and the work we do.

We have had another productive year in terms of our investigation outputs; at the same time, we have faced a number of serious challenges, in terms of both the complexity of the accidents and incidents we have had to deal with, and of the availability of resources.

By March of this year, planning our program for the next four years was showing that we would not be able to sustain the current level of staffing into future years. We took the difficult decision to reduce our complement of staff by twelve per cent. As a result, we have had to combine some of our functions, such as research and notifications, and our capacity is less than before in all teams including investigation, technical analysis and research and publication.

The decision to reduce our staff numbers was particularly difficult as it was made in the knowledge that there is no contingent workforce of highly skilled transport safety investigators available in the marketplace to be deployed at short notice in the event of a new crisis. It was indeed sobering to see more than 200 years of combined corporate and investigation experience leaving the ATSB.

In March, at the same time as we were required to undertake difficult decisions in relation to our staffing and resources, we received the news of the loss of Malaysia Airlines Flight 370 (MH370) and of its possible location in the Southern Indian Ocean, in Australia’s Search and Rescue Zone.

The ATSB became part of a whole of government response and worked closely with the Joint Agency Coordination Centre that was set up under the leadership of Air Chief Marshal (Retired) Angus Houston. We also worked closely with the Australian Maritime Safety Authority and other government agencies such as the Department of the Prime Minister and Cabinet and the
Department of Foreign Affairs and Trade together with our Malaysian counterparts.

Our subsequent involvement in leading the search for the missing Malaysia Airlines Flight 370 has presented us with our greatest challenge yet. This is the most serious aviation occurrence ever to involve the ATSB and its precursors, and is arguably the most mystifying, expansive and difficult search operation ever undertaken in the history of commercial aircraft. Since then, in July 2014, Malaysia Airlines Flight 17 (MH17) was apparently brought down by a missile over the Ukraine with a significant number of Australian citizens and residents on board. The ATSB deployed two investigators to the Ukraine to work in support of the Dutch Safety Board-led Annex 13 safety investigation into the occurrence. The ATSB will continue to provide support to investigation activities associated with the MH17 tragedy.

Introduction

The Australian Transport Safety Bureau (ATSB) 2012–13 Annual Report outlines performance against the outcome and program structure in the 2012–13 Infrastructure and Transport Portfolio Budget Statements. 

Chief Commissioner’s review 2012–13

2012–13 was the ATSB’s fourth year in its current form as a fully independent agency within the Infrastructure and Transport portfolio. It has been a productive year. Our investigations yielded a range of important safety messages that touched every element of transport, from the manufacturing of vehicles through to the effectiveness of operators’ systems and the routine procedures used in the course of a working day. Especially satisfying has been the conclusion of several unusually large and complex investigations.

It was also a year in which we developed as an organisation, moving beyond the consolidation of our business systems and governance arrangements, and devoting more of our attention to enhancing our systems and capabilities. By improving and expanding these resources, the ATSB is able to bring a better perspective to bear—both on transport safety in Australia and on our own operations. We can now identify safety trends sooner, gauge the implications more thoroughly, and share our insights with the transport community more quickly and more directly.

One of the most significant improvements has been the augmentation of our enterprise system, the Safety Investigation Information Management System (SIIMS). SIIMS is an electronic management system that captures and organises information about transport accidents, tracking them from the point of notification through to the completion of investigation. The new version gives our investigators additional tools to manage their work while affording our managers greater visibility of our work on hand. This will help us to plan and manage our workloads more effectively and to gauge the implications of shifting priorities as new issues requiring investigation emerge.

We have also developed an automated event risk classification system. This will assign a risk to every aviation occurrence reported to the ATSB, based on the type of operation and type of occurrence. The event risk ratings are used in a number of ways. In 2012–13 ratings were provided twice a day to managers for every immediately reportable matter and all notable routine reportable matters in order to assist in their decisions whether to initiate investigations.

We have further developed our capability to analyse our statistical information and to identify worrying trends. We are now sharing these new insights with important stakeholders in the industry in quarterly bulletins.

Finally, while our investigators have proven themselves capable of unravelling the most complex of events (and machinery), we know that the greatest insight in the world is worthless if it is not applied. Our mission is not only to investigate safety, but to share what we have learned with the transport community. In the past year, we have worked to advance the ways in which we disseminate our message. A focus on strategic communications has helped us to improve the clarity of our investigation reports so that they can be better understood by readers without technical knowledge.

Users of smartphones and other mobile devices are now able to view our website easily, thanks to the application of advanced web technology and our use of social media. 

Aviation

The aviation investigation teams completed 43 complex and 99 short aviation accident and incident investigations during the past year. Several of these garnered considerable national and international interest. Key accomplishments included the completion of one of the largest and most complex investigations in our organisation’s history, the uncontained engine failure on a Qantas A380 over Batam Island, Indonesia, which occurred on 4 November 2010 (AO-2010-089); pursuing the issue of potentially dangerous fuel tanks in Robinson R44 helicopters; and spelling out the implications of the fatal accident involving an air ambulance rescue operation in the Budderoo National Park near Wollongong, NSW.

The completion of the Qantas A380 investigation is a matter of particular satisfaction. After the initial discovery of the fatigue-cracked oil feed stub pipe that led to the engine failure, we continued to work with the engine manufacturer, Rolls-Royce, to confirm how the manufacturing fault had occurred and how to revise their procedures to prevent recurrence. We also worked with Airbus and international regulators to highlight the implications of the accident for airframe certification standards. Our report, released on 29 June 2013, was the culmination of two and a half years of hard work and cooperation with other agencies, and spelled out issues with significant implications for air safety around the world.

The past year also saw the resolution of a different safety issue, one that tragically claimed several lives. We investigated three accidents in Australia involving post-accident fires in R44 helicopters. This led us to reinforce previous warnings to operators about the need to replace rigid aluminium fuel tanks by the deadline of 30 April 2013. As a consequence, the Civil Aviation Safety Authority (CASA) issued an Airworthiness Directive that effectively grounded any remaining R44s that had not complied by the deadline.

Another significant accident involved an air ambulance helicopter, where paramedics were winched from the aircraft to rescue an injured canyoner. During the winching, a paramedic and the canyoner fell on to some rocks and the paramedic was fatally injured. Following the investigation, the Ambulance Service of New South Wales and the helicopter operator took safety action in respect of the operating scope applied to retrieval operations and procedures used by helicopter emergency crews. In addition, paramedics, in their role as ambulance rescue crewmen, are now required to conduct annual night winching currency training.

The release of our investigation report into the ditching of the Westwind Jet at Norfolk Island that occurred on 18 November 2009 (AO-2009-072) became a subject of the ABC’s 4 Corners program and was commented upon by other media outlets. A review of the investigation by a Senate Committee was launched late in 2012. The ATSB was required to make a number of detailed submissions, provide a great many documents and attend a number of hearings at Parliament House. The enquiry report was released on 23 May 2013. The Commission has carefully considered the report and has developed an action plan in response to matters raised in the report. The Australian Government is considering its response to the Committee.

Marine

The Marine Investigation team completed 11 investigations during the year, two of which were particularly significant for safe work in and around ships. The first concerned the grounding of the general cargo ship Tycoon at Flying Fish Cove on Christmas Island (MO-2012-001). Our findings on that accident have delivered important safety messages to the managers of the port. Following this incident, the port operator commenced a program of inspections, replaced important equipment and developed a handbook and safety training.

The second accident reinforced the ATSB’s ongoing concern about the safety of stevedores and crew members on board cargo ships, an issue tragically exemplified by the death of a stevedore who was crushed by aluminium ingots on board Weaver Arrow (MO-2012-010). The accident has resulted in safety actions intended to address the handling of such cargo as well as the issue of stevedore fatigue.

We also issued a highly significant report which made important recommendations about the safety of coastal pilotage in Queensland coastal waters (MI-2010-011). This is particularly topical as Australia sees the development of port facilities and the increasing transit of shipping carrying coal and gas along these sensitive regions, including the Great Barrier Reef.

Rail

From 20 January 2013, the ATSB assumed primary responsibility for rail investigations across Australia, as part of the new national system for rail safety. This expanded national role in rail transport safety reflects the progressive implementation of the August 2011 Intergovernmental Agreement on Rail Safety Regulation and Investigation Reform. As the national system is implemented in each State, the ATSB is assuming its expanded role there as the rail safety investigator. Since January, we have worked collaboratively with our state and territory colleagues to ensure adequate resources are or will be available to respond quickly and efficiently to safety events as they occur. The Rail Investigation Team completed six complex and three short investigations during the year.

Safety priorities

Last year, for the first time, the Commission identified eight safety priorities for the coming year.  These represent major risk areas that need ongoing and heightened attention from the Australian transport community:

• General aviation pilots—General aviation (GA) pilots continue to die in accidents that are mostly avoidable. Prominent among these accidents are those that involve low flying, wirestrikes, flying visually into bad weather, mismanagement of partial power loss and poor fuel management.
• Handling approach to land—There are a worrying number of cases where stability is not adequately assessed or uncommon manoeuvres are mishandled during an aircraft’s approach to land.
• Data input errors—Human error involving incorrect data entry continues to cause concern.
  In some cases, aircraft systems and operators’ flight management procedures are not catching these errors.
• Safety around non-towered aerodromes—Non-towered aerodromes continue to pose a risk to aircraft due to poor communication between pilots, ineffective use of see-and-avoid techniques and failure to follow common traffic advisory frequency (CTAF) and other procedures.
• Robinson R44 fuel tanks—A significant number of R44 helicopters were not fitted with bladder-type fuel tanks and other modifications detailed in manufacturer’s documentation that are designed to provide for improved resistance to post-impact fuel leaks and enhanced survivability prospects in the event of an accident.
• Under-reporting of occurrences—An ATSB investigation during 2011–12 into under-reporting of wirestrikes revealed approximately 40 per cent under-reporting of incidents and accidents. While there are a range of factors that could influence under-reporting of this particular occurrence type, it is likely that there is under-reporting of other occurrences, particularly those associated with GA operations.
• Safe work on rail—The ATSB has investigated several accidents that have occurred when maintenance work was being carried out on or near railway tracks. Conducting work on or near a railway track can be dangerous if safe working rules and procedures have not been correctly implemented to protect the worksite.
• Marine work practices—The ATSB has investigated several incidents involving unsafe working practices in the maritime industry. These incidents resulted in serious injury of death following falls from heights, crush, and equipment that exploded.

Upon release of our report (MI-2010-011) into Queensland coastal pilotage in October 2012, we added this as a further risk area. In order to publicise our concerns, and educate stakeholders about what they can do to improve their own safety, we developed a communications initiative, SafetyWatch. SafetyWatch is featured on the ATSB website and forms the focus for our industry and stakeholder engagement.

Outlook for 2013–14

Last year I commented that, with 56 larger aviation investigations on hand at the end of the financial year, we had reached what I judged to be a sustainable level of activity that was allowing us to meet our targets for timely investigations while maintaining the high quality of our work. We conclude this year with 65 larger aviation investigations on hand. This higher number reflects the level of resources we had to apply to our more complex investigations and some unplanned activities such as the Senate Inquiry. It also reflects that we are not fully meeting our performance standards for delivering investigations in a timely fashion. As we report elsewhere, more work needs to be done to improve the timeliness of our investigation reporting.

Like most government agencies, we are subject to the resource constraints imposed by the government’s efficiency and savings initiatives. This, combined with our work on the implementation of the National Rail Reforms and the new responsibilities they have brought, resulted in a year in which heavy commitments meant that we had to divert resources from other investigations with consequent delays.

The ATSB has never been resourced to undertake investigations into every accident or incident that occurs. Rather, it is necessary for us to be strategic, investigating those accidents and incidents that are likely to yield safety improvements for transport operators and the travelling public.

We can expect to continue to work in a resource-constrained environment during the foreseeable future and will need to be creative in finding ways to deliver the high quality expected by the government and the Australian public. Our responsibilities have grown in the rail sector and we are also acutely conscious of the effect on our available resources of the demands of one or more complex investigations.

More than ever we will need to be selective in deciding what matters to investigate in order to achieve the greatest value and confidence for the travelling public. Under current and forecast resource limits, a time is approaching when we will have to be more constrained as to which investigations and activities we can undertake and as to the extent of those investigations we do undertake. While we will continue to take all possible steps to mitigate it, the risk that we will miss an important issue increases as our resources diminish.

We continue to remain alert and prepared to handle a major accident in aviation, marine or rail and recognise the exceptional effort that would be required to respond. To ensure that we remain alert and responsive, our staff members continue to participate in planning and exercises and we continue to learn from our overseas counterparts.

We also continue to work with our neighbours in the region and to be an active and constructive player in the International Civil Aviation Organization, the International Maritime Organization and other international forums that have a role in transport safety. I am pleased that we have been able to assist our neighbours in the region during the year, using development cooperation funding from AusAID.

While the times are challenging, I remain enormously proud of the dedication and the accomplishments of our investigators and other staff. The technical knowledge and expertise within the ATSB is world-class. I thank the investigation and supporting staff of the ATSB whose efforts and expertise consistently enable us to provide an essential service to the Australian travelling public.

Martin Dolan
Chief Commissioner/CEO 

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  ATSB Annual Report 2012-13 (5.03 MB)

The Australian Transport Safety Bureau (ATSB) 2011–12 Annual Report outlines performance against the outcome and program structure in the 2011–12 Infrastructure and Transport Portfolio Budget Statements.

Chief Commissioner’s review 2011–12

This was the third year of the ATSB in its current form as a fully independent agency within the Infrastructure and Transport portfolio. The ATSB now has well developed business systems and governance arrangements to support its activities as Australia’s independent transport safety investigator. Our solid underpinnings have enabled us to expand our safety research, analysis and education functions.

At year’s end we had 56 larger aviation investigations on hand which represents a stable workload. This year only four of those investigations are over one year old, which demonstrates that we have reached a sustainable level of activity that allows us to meet our targets for timely investigation while maintaining the high quality of our work. The number of investigations in marine and rail has remained stable with 10 and 14 investigations outstanding.

Our short investigations have become a substantial component of our work. We released 90 short investigation reports in the past year. The capacity to undertake a larger volume of these short investigations provides excellent opportunities to deliver safety messages and for industry participants to learn from the experiences of others. In addition, although many of these investigations examine occurrences that are common and for which the underlying factors are well known, they serve to enhance the quality of the data held by the ATSB and act as a safety net to identify situations where more detailed or extensive investigation may be warranted.

This year we had a strong focus on engaging with our stakeholders and working even harder to disseminate our safety messages to ensure that they are understood and are acted upon. Our stakeholder survey gives us confidence that we are heading in the right direction but we recognise that we need to get even better at safety communication. This year we ventured into social media, using Twitter to let our stakeholders know about key issues and the release of our reports. This has proved very effective.

Aviation

The aviation investigation teams completed 11 complex and 127 less complex (includes 90 short) aviation accident and incident investigations during the past year. As usual several of these were of considerable national and international interest, identifying a number of safety issues that elicited commendable safety action by the relevant parties to reduce risk to the travelling public. These included:

• AO–2008–070. Injuries sustained by passengers and crew during the in–flight upset that occurred west of Learmonth, Western Australia on 7 October 2008 and involved a Qantas Airbus A330–303 (A330) aircraft, registered VH–QPA, reinforced the safety benefits of passengers having their seat belts fastened whenever they are seated. The upset resulted from a very rare series of intermittent, incorrect output spikes from one of the aircraft’s three air data inertial reference units (ADIRU). These data spikes were not appropriately processed by the aircraft’s flight control primary computers (FCPC), which then commanded the aircraft to pitch nose down. In response to this accident, the aircraft manufacturer revised the aircraft’s operational procedures to manage any repetition of the data spikes in the A330 and the ADIRU manufacturer modified the ADIRU to minimise the risk of a recurrence of the incorrect data spikes. In addition, the aircraft manufacturer incorporated revised software standards into the FCPC to prevent erroneous ADIRU data affecting aircraft pitch control.
• AO–2009–012. The investigation into the tail strike and runway overrun that occurred at Melbourne Airport, Victoria on 20 March 2009 involving an Emirates Airbus A340–541 aircraft, registered A6ERG, confirmed the fallibility of any system that relies on human input, particularly in the face of in–cockpit distractions. In this case, inadvertent and incorrect data entry into the aircraft’s performance systems could have resulted in the loss of the aircraft. Of importance, the investigation found that the use of erroneous take–off performance parameters was not new, and has occurred over time across a range of aircraft types, operators, operations and locations. Equally significant was that degraded take–off performance was generally not detected by flight crew until well into the take–off run (if at all), and that the take–off performance philosophy in civil transport aircraft did not require crews to monitor their aircraft’s acceleration or provide a required reference acceleration. In response, the operator and aircraft manufacturer undertook a number of procedural and equipment based safety actions. This included the commencement of the development of software that will detect discrepancies between the take–off speeds and check that the aircraft has sufficient runway length to support a take-off.
• AO–2010–019. The report into the crash of an Air North Embraer Brasilia aircraft, registration VH–ANB at Darwin Airport, Northern Territory highlighted the importance of the action by the Civil Aviation Safety Authority (CASA) to mandate the use of simulators for non–normal flying training and proficiency checks in larger aircraft. CASA has subsequently advised of changes to the simulator–based training requirements for such aircraft that will come into effect on 1 April 2013 and encouraged air operators to prepare early for the new rules. The flight had been for the purpose of revalidating the command instrument rating of the pilot under check and was under the command of a training and checking captain, who occupied the copilot’s seat. The take-off included a simulated engine failure which led to a loss of control and the deaths of the two pilots.
• In aviation, we are continuing our work to understand and mitigate the number of breakdowns of separation (BOS) and losses of separation assurance (LOSA) in air traffic control. Although the rate of these occurrences this year was broadly reflective of earlier years, we continue to examine individual occurrences in order to prevent their recurrence, but have also initiated a safety research investigation to bring the results of completed investigations together and compare their results with each other and the overall occurrence data set. To date, no significant, systemic safety issues have been identified as a result of our ongoing assessment of BOS/LOSA occurrences. If they had, the ATSB would already have drawn it to the attention of Airservices Australia or the Department of Defence so that they could begin safety action in response. If any significant, systemic safety issue is identified in the future, it will immediately be brought to these organisations’ attention.

Marine

The marine investigation team completed 10 investigations during the year, two of which were particularly significant for safe work in and around ships.

• MO–2010–002. The report into the death of a stevedore who was crushed between two containers during loading operations on board the container ship Vega Gotland, while it was berthed at the Patrick Terminals Port Botany facility identified some very important safety issues for workers handling cargo in loading facilities. The ATSB investigation found that the lashing team leader had placed himself in a position of danger and that when a twist lock foundation unexpectedly failed during the repositioning of the container, he was unable to get clear of the swinging container. The investigation identified that while the dangers of working between a moving container and a fixed object were taught to Patrick Terminals’ new employees during their induction training, the issue was not specifically covered or reinforced in the company’s safe work instructions, the hazard identification and associated risk control processes nor, in some instances, followed in practice by stevedores on board the ships in the terminal. The ATSB identified safety issues during the investigation and Patrick Terminals undertook extensive work to correct the causal issues in this accident.
• MO–2010–004. On 16 May 2010, the chief engineer, second mate and fourth engineer of the Isle of Man registered liquefied natural gas tanker British Sapphire were injured when the fast rescue boat they were in dropped 18 m to the water while being launched. The second mate and fourth engineer were part of the rescue boat’s three crew involved in an attempt to transfer the chief engineer to a police launch for medical evacuation. The investigation determined that, in the process of lowering the rescue boat, the wave compensator mechanism on the fast rescue boat’s davit was activated early, before the rescue boat had reached the water. A fail–safe interlock device should have prevented this by placing the wave compensator into standby mode, only becoming operational when the fast rescue boat was waterborne. However, the electrical installation of the interlock was incorrect and meant it could not work as designed, allowing the wave compensation unit to operate always and the fast rescue boat to make the uncontrolled descent to the sea. The investigation identified safety issues relating to the commissioning, maintenance, testing, operating instructions and procedures for the fast rescue boat’s wave compensator and its safety interlock system. Further safety issues were identified relating to the job hazard analysis for the use of the fast rescue boat, crew resource management principles and approved training courses for fast rescue boats. During the investigation, the ATSB was satisfied that the safety action taken by BP Shipping and Davit International addressed the identified safety issues. However, the ATSB remained concerned about the adequacy of training in the use of wave compensation units on fast rescue boat davits and released a safety advisory notice to national and international maritime training institutions about this safety issue.

Rail

The Rail Investigation Team completed 12 investigations during the year. Two of these highlighted significant safety issues.

• RO–2010–004. In May 2010 a collision between an XPT passenger train and a track–mounted excavator near Newbridge, NSW resulted in the death of the excavator operator. The workers were operating under Track Occupancy Authorities (TOA) and had been authorised to occupy and work on the tracks. Neither the Protection Officer (PO) nor the Network Control Officer (NCO) had positively identified the location and type of worksite. Their actions were influenced by a deficiency in the TOA form, in that no provision was provided to record this critical information. Both the PO and the NCO had wrongly assumed that the train had already passed beyond the limits of the worksite. The problem was compounded when the workers accessed the danger zone before the PO had put in place the normal site protection measures such as detonators and flags. As a result, the Australian Rail Track Corporation (ARTC) reinforced the rules and procedures for the issuing of TOAs. The ARTC also implemented a revised TOA form that records critical information about the location and type of worksite.
• RO–2010–015. A freight train 1MP5 derailed on the Trans–Australian Railway Line at Goddards, approximately 240 km east of Kalgoorlie in Western Australia. The derailment occurred within a recently constructed crossing loop on a section of track managed by the ARTC. Train 1MP5 consisted of two locomotives hauling two crew vans and 49 wagons. There were no injuries as a result of the derailment but 23 wagons derailed, many of which were significantly damaged (including all triple–deck car carrier wagons) and about 700 m of track required replacement. The ATSB determined that the derailment was a result of flange climb initiated by a track misalignment which probably grew as train 1MP5 traversed it, initiating the derailment. Factors that contributed to the misalignment were the high ambient temperature, inadequately de–stressed rail and insufficient ballast through the derailment site. The ATSB also found that the ARTC’s quality assurance processes used during the construction of the crossing loop could be improved. 

Safety priorities

In setting the ATSB’s safety priorities for the coming year, the ATSB has identified the following main risk areas that need ongoing and heightened attention from the Australian transport community:

• Avoidable aviation accidents—General Aviation (GA) pilots continue to die in accidents that are mostly avoidable. Prominent among these accidents are those that involve low flying, wirestrikes, flying visually into bad weather, mismanagement of partial power loss and poor fuel management.
• Handling of approach to land—There is a worrying number of cases where stability is not adequately assessed or uncommon manoeuvres are mishandled during an aircraft’s approach to land.
• Aircraft performance calculations and data input errors—Human error involving incorrect data entry continues to cause concern. In some cases, aircraft systems and operators’ flight management procedures are not catching these errors.
• Safety in the vicinity of non–towered aerodromes—Non–towered aerodromes continue to pose a risk to aircraft due to poor communication between pilots, ineffective use of see–and–avoid techniques and failure to follow common traffic advisory frequency (CTAF) and other procedures.
• Robinson R44 fuel tanks—A significant number of R44 helicopters are not fitted with bladder–type fuel tanks and other modifications detailed in manufacturer’s documentation that are designed to provide for improved resistance to post–impact fuel leaks and enhanced survivability prospects in the event of an accident.
• Reporting of accidents, incidents and transport safety concerns—An ATSB investigation during 2011–12 into under–reporting of wirestrikes revealed that there was around 40 per cent under–reporting of incidents and accidents. While there is a range of factors that could influence under–reporting of this particular occurrence type, it is likely that there is under–reporting of other occurrences, particularly associated with GA operations.
• Rail safe working irregularities—We continue to draw the attention of track maintenance organisations to the need for adherence to rules and procedures, improved procedures and training and effective communication between train controllers, train crew and track workers.
• Unsafe marine work practices—we are still seeing risk to life from unsafe work practices in or around ships and loading areas. We will continue to focus on this area to improve the safety of work at sea.

Implementation of the National Rail Safety Reforms

The implementation of the ATSB’s expanded national role in rail transport safety, as agreed in August 2011 under the Intergovernmental Agreement (IGA) on Rail Regulation and Investigation Reform, is on track to begin operation from January 2013. The ATSB, as Australia’s national safety investigator, will assume primary responsibility for rail investigations across Australia as part of a broader national transport reform process. This will shift our workload in the rail mode considerably, as we expect to receive a far greater number of notifications of rail incidents and accidents than at present, and with a greater emphasis on passenger trains.

As implementation progresses we will work collaboratively with our state and territory colleagues to ensure adequate resources are available for the task. This will allow us to develop the capacity to respond quickly and efficiently to safety events as they occur.

Outlook for 2012–13

This year we plan to continue our work across a range of fronts we have spelled out in our annual plan, participating actively in the transport reform agenda, seeking improvements in the efficiency and effectiveness of our investigations, strengthening our relationships with stakeholders and sharing safety information. We continue to ensure that our safety research and data analysis is world class with the aim of identifying and responding to emerging trends in safety.

We will also continue to engage with our neighbours in the region and to be an active and constructive player in the International Civil Aviation Organization and the International Maritime Organization and other international and regional forums that have a role in transport safety. And as always, we must remain alert and prepared for a major accident, testing and improving our preparedness.

During the forthcoming year we will face significant financial constraints as we adapt to the Government’s efficiency dividend and find ways to deliver the high quality expected by the Government and the Australian public within the constraints of the resources made available to us. Our expanding role in the rail sector will require us to work smarter and to allocate resources carefully.

Finally, I must once again thank the investigation and supporting staff of the ATSB whose efforts and expertise consistently enable us to provide our essential safety service to the Australian travelling public.

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, which still represents about 80% of our investigation task: there were 51 larger aviation investigations on hand at the end of this year, compared to 70 last year. This represents a sustainable level of activity that will allow us to meet our targets for timely investigation while maintaining the quality of our work. The number of investigations on hand in rail and marine has remained relatively stable by comparison.

Later in my review I have highlighted some larger investigations that have raised significant issues in transport safety. It is a requirement of the Transport Safety Investigation Act 2003 that I report on this, but it is also important to show that our work of investigation leads both to the identification of problems and to the implementation of practical solutions to those problems in the interests of improved transport safety.

The reduction in the backlog of larger investigations was matched by a substantial increase in our 'short' investigation output. As highlighted last year, we have developed a targeted capacity to produce timely, short investigation reports which compile information on the circumstances of a safety occurrence and on any safety action that may have been taken or identified as a result.

The Short Investigations team produced 19 reports in 2009-10. This increased to 52 reports in 2010-11. As set out later in this review, these reports are already showing their value in providing more detailed data on a larger number of safety occurrences and indicating safety trends. In addition, they assist Australia in meeting its international obligations to investigate all accidents and serious incidents. They are also a highly effective way of illustrating safety messages with real and timely examples.

The work of consolidating our investigation function has been matched by expanded activity in research, analysis and education. As well as improving the quality and usefulness of our statistical publications in all three transport modes, we are also turning good research into practical education material. This is allowing the ATSB to address one of the key issues identified in last year's annual report: shifting the emphasis in our general aviation work towards good practical safety educational material based on sound research. We have also made significant advances in finding better ways to engage with our stakeholders, including through a more user-friendly web presence and through judicious use of social media.

Aviation safety investigations

The aviation investigation teams completed 113 aviation accident and incident investigations in the past year, several of which attracted substantial national and international interest. Many of those investigations, and the remaining ongoing investigations, have helped to identify important safety issues and to bring about significant safety improvements.

One significant investigation (AO-2008-003) was an occurrence involving a Boeing 747-438 aircraft which was subject to a number of electrical power-related malfunctions affecting many of the aircraft's communication, navigation, monitoring and flight guidance systems. While the consequences were potentially very serious, the aircraft's engines and hydraulic and pneumatic systems were largely unaffected and the aircraft landed safely at Bangkok.

The malfunctions were found to have been caused by leaks resulting from an overflowing galley drain. The investigation identified a number of serious and systemic safety issues regarding the protection of aircraft systems from liquids. In response, the aircraft manufacturer and operator implemented a number of safety actions intended to prevent a recurrence. In addition, the United States Federal Aviation Administration issued a notice of proposed rulemaking to adopt a new airworthiness directive for certain 747-400 and 747-400D series aircraft to install improved water protection. The ATSB issued two safety recommendations and one safety advisory notice as a result of the investigation (see Table 7 for details).

In a similar vein, a separate investigation (AO-2009-004) highlighted significant electrical problems associated with inadequate waterproofing in AgustaWestland AW139 helicopters. In response, the manufacturer initiated several actions to rectify the problem and the ATSB is satisfied that action adequately addresses the safety issue.

Another investigation (AO-2009-065) highlighted potential problems with unreliable airspeed indications in Airbus A330 and A340 aircraft. When airspeed data is unreliable, some aircraft systems respond in ways that pilots do not encounter often. Airspeed data is derived from mechanisms called pitot probes, which respond to variations in the airflow outside an aircraft.

In the occurrence the ATSB investigated, involving an Airbus A330-202 aircraft, there was a brief period of disagreement between the aircraft's three sources of airspeed information. The autopilot, auto-thrust and flight directors disconnected, and the flight control system reverted to alternate law, which meant that some flight envelope protections were no longer available. There was no effect on the aircraft's flight path, and the flight crew followed the operator's documented procedures. The airspeed disagreement was due to a temporary obstruction of the captain's and standby pitot probes, probably due to ice crystals. A similar event occurred on the same aircraft on 15 March 2009.

Both of the events occurred in environmental conditions outside those specified in the certification requirements for the pitot probes. That is, the certification requirements were not sufficient to prevent the probes from being obstructed with ice during some types of environmental conditions. As a result of its own investigations of similar occurrences, the French Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile (BEA) has recommended the European Aviation Safety Agency (EASA) to review the certification criteria for pitot probes in icing environments. The ATSB is satisfied that this work, when complete, will address this significant safety issue.
The ATSB played a significant role in support of the Papua New Guinea (PNG) Accident Investigation Commission (AIC) investigation into the controlled flight into terrain that occurred near Kokoda, PNG on 11 August 2009 and involved a de Havilland Canada DHC-6 Twin Otter aircraft.

The investigation identified a number of factors that led to increased safety risk. These related to the crew of the aircraft, the weather conditions affecting the flight, crew training and the conduct of the flight. A number of the safety factors had the potential to adversely affect the safety of future aviation operations.

As a result of the investigation, the AIC PNG issued a safety recommendation in respect of the installation of cockpit voice recorders (CVR) in PNG aircraft with a seating capacity of 18 or more passengers. In response, the Civil Aviation Safety Authority of PNG (CASA PNG) is proposing legislation to require the installation of CVRs in turbine-powered aircraft with seating for more than nine passengers. As a result of the investigation, CASA PNG has also established a principal medical officer position and has advised of action to move responsibility for the administration of the PNG mandatory occurrence notification system to the AIC PNG. Extensive proactive safety action has been taken by the aircraft operator in response to the risk of inadvertent flight into cloud while employing visual flight procedures and regarding operations into Kokoda Airstrip, in an effort to prevent a recurrence. The investigation report (AE-2009-050) is available from the ATSB website.

Finally, the ATSB is continuing to investigate an uncontained engine failure on a Qantas Airbus A380 aircraft over Batam Island, Indonesia on 4 November 2010. The aircraft's No 2 engine had sustained an uncontained failure of its intermediate pressure turbine disc. Sections of the disc had penetrated the left wing and the left wing-to-fuselage fairing, resulting in structural and systems damage to the aircraft.
Within a month of the accident, the ATSB, leading an investigation that involved a range of other countries and major corporations, had established the presence of fatigue cracking within a small stub pipe that feeds oil into one of the engine's bearing structures. The fatigue was attributed to misaligned counter-boring of the stub pipe as part of the engine manufacturing process. Such fatigue cracking, if it occurred in other engines, had the potential to create oil leakage which could lead to catastrophic engine failure from a resulting oil fire.
As a result of this work, a number of safety actions were immediately undertaken by Qantas, the Australian Civil Aviation Safety Authority, Airbus, Rolls-Royce plc, and the European Aviation Safety Agency that enabled the resumption of safe flight by all aircraft equipped with the failed engine type.

The ATSB prepared a preliminary factual report on the investigation of the occurrence. That report was publicly released on 3 December 2010. The investigation continues so that all the safety implications and lessons from the accident, including positive lessons about how the emergency was handled, can be reviewed and published.

Other investigations also identified significant safety issues relating to the safety of air transport. These related to the supervision of agricultural pilots, training and supervision of charter pilots, potentially hazardous helicopter winching procedures, turbulence caused by buildings at airports, airspace design and management and problems with the management by air traffic control of compromised separation of aircraft. In each case, the ATSB was satisfied that action had been taken or was in train to address the identified safety issues.

Marine safety investigations

The marine investigation team completed 11 safety investigations. While all investigations are conducted by the ATSB with the aim of identifying and promulgating useful safety messages, three raised significant issues for transport safety.

The first was the loss overboard of containers from the container ship Pacific Adventurer.

On 11 March 2009, the Pacific Adventurer lost 31 containers overboard in gale force weather conditions and large swells off Cape Moreton, Queensland. The cargo included 50 containers of ammonium nitrate in the form of prills. The substance, which is used as an oxidiser in the mining industry, is classified as dangerous goods under the International Maritime Dangerous Goods Code.

All the containers sank, and two of the ship's fuel oil tanks were holed as the containers went overboard. About 270 tonnes of oil leaked from the holed tanks and 38 miles of Queensland coastline was affected by oil pollution.

The ATSB investigation (MO-2009-002) found that the ship was probably subjected to synchronous rolling at the time and that the severe and sometimes violent rolling motions caused the lashings on the containers, and possibly some containers themselves, to fail. In addition, much of the fixed and loose container lashing equipment was in a poor condition and the inspection and replacement regime in the ship's safety management system had not been effectively implemented.

The ATSB identified four safety issues during the investigation: the inspection and maintenance regime of the ship's fixed and loose lashing equipment had been deficient; there was no requirement for a third party to inspect this equipment; the cargo in the containers which were lost overboard was not packaged in accordance with international dangerous goods shipping requirements; and the dangerous goods shipping compliance audit regime did not pick up on this fact.

Safety action to address the safety issues was taken by several of the responsible organisations. The ATSB has issued one safety advisory notice in regard to the outstanding safety issue concerning third party inspections of lashing equipment.

The second investigation of particular significance involved the grounding of the bulk carrier Shen Neng 1.

On 3 April 2010, the Chinese registered bulk carrier Shen Neng 1 grounded on Douglas Shoal, about 50 miles north of the entrance to the port of Gladstone, Queensland. The ship's hull was seriously damaged by the grounding, with the engine room and six water ballast and fuel oil tanks being breached, resulting in a small amount of pollution.

The ATSB investigation (MO-2010-003) found that the grounding occurred because the chief mate did not alter the ship's course at the designated course alteration position. His monitoring of the ship's position was ineffective and his actions were affected by fatigue.

The ATSB identified four safety issues during the investigation: there was no effective fatigue management system in place to ensure that the bridge watchkeepers were fit to stand a navigational watch after they had supervised the loading of a cargo of coal in Gladstone; there was insufficient guidance in relation to the proper use of passage plans, including electronic route plans, in the ship's safety management system; there were no visual cues to warn either the chief mate or the seaman on lookout duty, as to the underwater dangers directly ahead of the ship; and, at the time of the grounding, the protections afforded by the requirement for compulsory pilotage and active monitoring of ships by the coastal vessel traffic service REEFVTS were not in place in the sea area off Gladstone.

The ATSB has issued two safety recommendations to Shen Neng 1's management company regarding the safety issues associated with fatigue management and passage planning and acknowledges the safety action taken by the Australian Maritime Safety Authority (AMSA) in relation to the extension of REEFVTS coverage to include the waters off Gladstone.

The third investigation of particular significance was into the grounding of products tanker Atlantic Blue. This investigation (MO-2009-001) was significant in that it was the initiator for an ATSB safety issues investigation into the adequacy from a safety perspective of the whole Australian coastal pilotage regime. This investigation is still under way and will examine the systemic issues involved in coastal pilotage.

Another investigation (MO-2008-013), arising from a fatality, identified a gap in the regime for regulating work safety at sea. While work is in train to change the relevant legislation, the risk remains that, during some operations, it is possible a ship would not come under the jurisdiction of any Australian safety regulatory regime.

Rail safety investigations

The rail investigation team completed nine transport safety investigations in the past year and issued six preliminary factual reports. Three of these investigations identified significant safety issues.

The first (RO-2009-009) occurred at Cootamundra, New South Wales and involved a passenger train almost colliding with the last wagon of a stationary freight train. This was despite the signal indicating that the route the passenger train was taking was set and unobstructed. The investigation determined that a signalling system design error allowed the signal to be cleared for the passage of the passenger train, even though its route was obstructed by the freight train, which was on the adjacent line. The ATSB is satisfied that actions taken by the track operator should mitigate the risk of a similar occurrence.

The second investigation (RO-2009-008) involved a passenger train, en route from Melbourne to Sydney, which passed a signal by about 33 m while it was displaying a Stop (red) indication. While no injuries or damage resulted from the occurrence, the report identified three safety issues in relation to prioritisation of operational tasks, signal lamp voltage and signalling design standards.

The third involved a safe-working incident within the Junee station yard limits when a locomotive was moved from one road to another without authority while a Track Occupancy Authority (TOA) was in force. TOAs are designed to prevent such movements so as to protect workers on the track. While no injuries or damage resulted, the investigation found problems with the overall management of and communication about TOAs that are yet to be resolved to the ATSB's satisfaction.

Safety trends

I referred earlier to the Short Investigation team and how its work complements that of established investigation teams by providing more detailed data on a larger number of safety occurrences for future research and analysis. The team produced three bulletins containing a total of 52 short summary reports in the course of the year. Examining these in conjunction with our research reports and our larger investigations draws out some potentially significant safety trends in Australian aviation.

The first is the continuing prevalence of incidents and some accidents involving inadequate execution by pilots of 'see-and-avoid' procedures in the vicinity of smaller airports. The ATSB has consistently drawn attention to the limitations of 'see-and-avoid', but work remains to be done in making sure pilots understand and respond to this.

The second is a range of occurrences which involve issues with the training, checking and supervision of pilots. This trend is independent of the total hours of flight experience pilots have and often involves the execution of normal but rarely used procedures. The ATSB will continue to monitor this area to see if the underlying issue can be drawn out more clearly.

Third is the number of occurrences involving the breakdown of air traffic control separation of aircraft or problems in recovery of a compromised separation. Airservices Australia has taken safety action to deal with recovery from compromised separation (see investigation report AO-2009-080), but several investigations currently under way are likely to clarify whether a series of separation breakdowns point to any systemic safety issue.

Finally, there are a number of safety occurrences in general aviation which point to a continuing exposure to known risks: a sequence of collisions with previously identified powerlines; poor management of fuel leading to fuel exhaustion; and pilots flying visually into instrument conditions. As was indicated in last year's report, the ATSB has dealt with the continuing prevalence of these types of occurrence by the production of focused educational material for pilots and by conducting safety education programs based on this material.

In the course of a number of rail investigations, the ATSB continues to observe a concerning pattern of safe-working irregularities, including one resulting in a fatality. We draw the attention of track maintenance organisations to the need for adherence to rules and procedures, improved procedures and training, and effective radio communication between train controllers and train crew and track workers.

Three marine investigations, two arising from a fatality and the other from a serious injury to a seafarer, highlighted the continuing risk to life of unsafe working practices. While in each case the necessary action has been taken to manage the hazardous work, much still remains to be done to ensure the safety of work at sea.

Outlook for 2011-12

This review reflects the continued preponderance of aviation in the ATSB's work. The next two years, however, will see a substantial growth in our role in the rail sector as we take on primary responsibility for all rail investigations across Australia as part of a broader national transport reform process. It is likely, although not yet agreed by governments, that we will acquire similar national responsibilities in the maritime sector.

This expansion of the ATSB's scope sets challenges for us that I am confident we will rise to: collaborative work with our state and territory colleagues to ensure adequate resources are available for the task; management and use of national safety data sets for the rail and maritime sectors; and the capacity to respond quickly and effectively to safety events as they occur.

In parallel with this, we will start to reap the benefits of consolidating our existing investigative work. In particular, we have freed up some of the time of our investigators to focus on systemic investigations of developing safety issues with the aim of preventing accidents. Our current investigations of the overall safety of marine coastal pilotage and of safety issues associated with the Melbourne to Sydney rail line are examples of our growing capability in this area.

We will also maintain our enhanced focus on engaging with stakeholders and discharging our responsibility for transport safety education. We will work harder to ensure that the safety messages from our investigations are understood and acted on, while still ensuring that our investigations and their associated reports are comprehensive, rigorous and timely.

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. At the same time, the ATSB continued to deliver its core business of conducting transport safety investigations, some of which were complex and the subject of significant industry and public interest both in Australia and internationally. A number of those investigations led directly to significant initiatives to improve transport safety.

Legally, the ATSB consists of three Commissioners: Mr Noel Hart, Ms Carolyn Walsh and me. The three of us are generally referred to as 'the Commission'. As the Chief Commissioner, I am also Chief Executive Officer of the ATSB, with responsibility for the employment of staff and the management of financial and other resources.

One of the Commission's most important responsibilities is to ensure that a transport safety investigation is complete and that a final report can be published; this includes determining what important safety messages arise from an investigation and the best means to communicate those messages.

The Transport Safety Investigation Act 2003 reinforces this responsibility: it requires the Chief Commissioner to describe in the ATSB's annual report those investigations that have raised significant issues in transport safety. This review meets that requirement. Some of the investigations described below are not yet finished. It is the ATSB's policy, however, to bring critical safety issues to the immediate attention of those best placed to take prompt action.

Rail safety investigation

The rail investigation team completed 11 transport safety investigations in the past year. Two of those investigations were conducted on behalf of the Queensland Department of Transport and Main Roads, in accordance with provisions of Queensland's Transport Infrastructure Act 1994, with a senior ATSB rail safety investigator as the independent chair of the investigation team. These high‑profile investigations involving passenger trains at level crossings were conducted in a timely manner and resulted in wide‑ranging safety action by the Queensland Government.

They and other investigations highlight the continuing issues of road design, marking and road use that are the most significant influences on safety at level crossings, particularly where heavy road transport vehicles are involved.

In the course of a number of other investigations, the ATSB continues to observe a concerning pattern of safe‑working irregularities, including some resulting in fatalities, that are principally attributable to communications issues. We draw the attention of rail operators to the need for improved procedures and training in effective radio communication between train controllers and train crew and track workers.

Marine safety investigation

The marine investigation team completed 11 safety investigations, including one in assistance to the New Zealand Transport Accident Investigation Commission (TAIC). While all investigations are conducted by the ATSB with the aim of identifying and promulgating useful safety messages, there were two in particular that, from my perspective, raise significant issues in transport safety.

The first is the collision of the yacht Ella's Pink Lady and the bulk carrier Silver Yang. The investigation found that when the two vessels collided, neither the yacht's skipper nor the ship's watch keepers were keeping a proper lookout, nor were they appropriately using navigational aids to manage the risk of collision. The investigation also found that following the collision, the ship's watch keeper did not adequately offer to assist the yacht's skipper.

Failure to stop and render assistance is a problem that has also been highlighted by previous ATSB investigations and is a continuing problem around the world.

The investigation serves as a timely reminder that, under United Nations conventions, ship operators have an obligation to offer assistance immediately to other vessels following a collision.

The second significant investigation involved the container ship APL Sydney, which ruptured the submarine ethane gas pipeline in Port Phillip after dragging its anchor across the pipeline in strong gale force winds.

The ship's anchor had been let go too close to the pipeline in poor weather conditions and insufficient anchor cable was deployed. Inadequate action was taken on board the ship and at harbour control to prevent the anchor from snagging the pipeline. After snagging the pipeline, the anchor windlass failed. Instead of releasing the fouled anchor, an attempt was made to clear it and this led to the pipeline rupture.

After the rupture, APL Sydney was manoeuvred clear of the escaping gas and the pipeline. There were no injuries and the pipeline was isolated. The anchor cable was cut and left in the anchorage with the anchor. Repairs to the pipeline took several months.

The ATSB investigation identified 10 significant safety issues in relation to the port's risk management, with respect to the pipeline and anchorage boundaries and its shipping control procedures, the ship's safety management system, the pilotage company's safety management system, and the windlass failure. Safety action to address all of the safety issues identified was proactively taken by the relevant parties.

Of particular significance, given other investigations and occurrences internationally, are the ongoing issues of effective bridge resource management when a pilot is on board a vessel. The ATSB draws attention to the need for training of pilots and deck officers to give emphasis to issues of role clarity between pilots and officers, cross‑cultural issues and the need for clear communication protocols.

Aviation safety investigation

The aviation investigation teams completed 68 aviation accident and incident investigations in the past year, several of which attracted substantial national and international interest. Many of those investigations, both completed and ongoing, have helped to identify important safety issues.

The first is an occurrence involving an A320 aircraft that performed an incorrect go‑around in fog at Melbourne Airport. In the process, the crew was unaware of the aircraft's current flight mode. The aircraft descended to within 38 ft of the ground before climbing.

The investigation highlighted the risks of changing standard operating procedures, particularly without formal risk management processes. Even more significantly, it provided more evidence that issues remain about the adequacy of some elements of oversight and delivery of pilot training. These issues are also coming into prominence in a number of other aviation investigations.

The aircraft operator has commenced a review of its flight training requirements, and the Civil Aviation Safety Authority (CASA) is reviewing the regulations relating to the provision of flying training by third party training providers. The ATSB nevertheless draws attention to the safety significance of effective training oversight, whether delivered by third parties or in‑house. The ATSB will be directing further investigative efforts to this area of potential safety risk.

The second is an occurrence involving an Embraer 120 aircraft at Jundee Airstrip, Western Australia. On final approach to the airstrip, the aircraft unexpectedly drifted left of the runway centreline and the crew decided to initiate a go‑around, whereupon the aircraft violently rolled and yawed left. The crew had difficulty controlling the aircraft and narrowly avoided colliding with the ground.

The ATSB investigation established that the left engine had sustained a total power loss following fuel starvation. That had occurred because the left fuel tank was empty.

The ATSB identified multiple safety factors associated with the fuel quantity indicating system, the ability of the crew to recognise the left engine power loss, and their performance during the go‑around.

After the incident, the operator introduced revised procedures for measuring fuel quantity, and CASA initiated a project to amend the guidance to provide better clarity and emphasis. In March 2009, an EMB‑120 flight simulator came into operation in Melbourne, Victoria. CASA has advised that a Notice of Proposed Rule Making relating to simulator training requirements will be released by the end of July 2010 with a response period of six weeks. Final rule making is expected to be accomplished toward the end of the calendar year.

The occurrence does, however, also draw attention to several other significant safety issues that are also appearing in other investigations. These include a pattern of problems with stabilised approaches to landing, a number of instances of potential and actual accidents arising from inadequate fuel management, and some early indications of systemic problems with the handling of asymmetric engine conditions.

In each of these cases, the ATSB will be doing further work to establish the scope and scale of the problem. In the meantime, we encourage operators to make their own assessments in these areas to satisfy themselves that the risk is as low as reasonably practicable.

Finally, the ATSB draws attention to an aspect of its trend analysis of safety in general aviation. The fatality rate has not significantly varied over the last ten years, nor has the relative proportion of the major contributors to those fatalities: fuel management, controlled flight into terrain, wire strikes and visual flight in instrument conditions. Detailed investigation is adding little safety value. It is clear that a shift of emphasis to greater safety education is necessary.

This publication represents the last in a series of annual reviews, dating back to 1999-2000.

Over the last ten years, the Bureau has built a reputation as a world class investigative organisation. This has been chronicled through the ten annual reviews which the ATSB has released.

From 1 July 2009, the ATSB has taken on new annual reporting responsibilities which will result in the publication of a very different document. This change is entirely appropriate given the ATSB's status as a newly established statutory agency. However, consistent with our new mandate, I know the Commission will be looking for additional vehicles, similar to the Annual Review, to share the insights our investigations have uncovered and to promote transport safety.

As the ATSB's first Chief Commissioner, I am proud to lead the fine organisation I have inherited from Kym Bills. The successes achieved over the last ten years provide us with a solid foundation on which to achieve the expectations of government. I thank Kym for his dedication, hard work and for his outstanding legacy.

Martin Dolan
Chief Commissioner

The ATSB Annual Review 2003 documents ATSB's achievements and safety activities from 1 July 2002 to 30 June 2003 and outlines its business planning for 2003-2004

Executive Director's message

During 2002-03, the ATSB assisted the Minister for Transport and Regional Services with new legislation to enable the Bureau to investigate rail accidents on the increasingly important interstate system. The Transport Safety Investigation Act 2003 (TSI Act) also updates and harmonises the Bureau's aviation and marine investigative powers. The Transport Safety Investigation Regulations 2003 were also finalised this year following industry consultation and commenced together with the TSI Act on 1 July 2003.

In 2002-03 the ATSB further developed its website www.atsb.gov.au which contains the new legislation and all ATSB reports, recommendations, and key safety information and receives more than five million hits' each year.

In August 2002, the Bureau received national tertiary accreditation for five years for its internal competency-based Diploma in Transport Safety Investigation. The Diploma will validate that ATSB investigators have reached a minimum competency standard linked to investigator work level standards.

The ATSB has worked closely with state and territory transport agencies and other major stakeholders, through the National Road Safety Strategy Panel, and coordinated the development of a National Road Safety Action Plan for 2003 and 2004. The Action Plan was endorsed by Australian Transport Council (ATC) Ministers in November 2002 and covers priority areas including more effective speed management, expansion of road-based treatments, enhanced drink-driving deterrence, and measures to reduce fatigue-related harm. The Action Plan seeks to accelerate progress towards reducing the national road fatality rate by 40 per cent by 2010.

Senator Ron Boswell in his role as Parliamentary Secretary, released a number of well-received ATSB research and statistical reports and a number of other road safety publications throughout the year. A special analysis of fatal crashes over the Christmas/New Year holiday period was undertaken at the request of the Minister. The ATSB also worked closely with the National Road Transport Commission to develop a heavy vehicle safety strategy which was approved by ATC Ministers in May 2003.

The ATSB continued to participate in rail safety investigations at the invitation of state governments. Since 1999, the Bureau has undertaken or taken part in 14 investigations. Most have been in Victoria, but others have involved WA, NSW, Queensland and SA. Investigations have brought about important safety changes including to operational practices, infrastructure and regulation. The ATSB highlighted the potential inadequacies with deadman's handle' braking devices in the event of driver incapacitation in its Footscray and Epping reports.

In 2002-03, the 13 marine reports released included the October 2002 report of a ballast tank explosion on the Hong Kong registered Nego Kim with eight fatalities. Its recommendations led to both operator safety action and broader recommendations for improved safety procedures for future painting and similar work in enclosed spaces.

The ATSB released 78 final air safety investigation reports during 2002-03. A major report on maintenance problems with the Ansett Boeing 767 fleet has been especially well received in Australia and internationally and has been nominated for an international air safety award. The Bureau was pleased that in many cases safety action was undertaken obviating a need for a recommendation. Most recommendations made also led to positive safety action.

At the invitation of the East Timor Government the ATSB is leading an investigation into the fatal crash of an Ilyushin IL-76TD aircraft near Baucau, East Timor in a joint investigation with the Australian Defence Force and in cooperation with Russian investigators.

The findings on 12 September 2002 of a WA Coronial inquest into a charter accident involving Beech King Air VH-SKC included some criticisms of the ATSB. While the Bureau accepted that in hindsight there were areas it could improve upon in future investigations if additional resources were applied, other criticisms were not accepted, including criticism of the basis for independent ATSB no blame investigations under Annex 13 to the Chicago Convention.

A Coronial inquest into the accident involving Whyalla Airlines Piper Chieftain VH-MZK commenced hearings on 22 July 2002, and the SA State Coroner delivered his findings on 24 July 2003. The process also involved civil damages litigation in the US and required substantial Bureau resources to be diverted from other safety priorities. The ATSB formally reopened its VH-MZK investigation after the US engine manufacturer issued a service bulletin in September 2002 which included MKZ's left crankshaft. The ATSB will deliver a supplementary investigation report later in 2003.

During the year the Bureau continued to liaise with and seek to improve cooperation and mutual understanding with coroners around Australia, and this remains a priority for 2003-04 based on the ATSB's new legislative framework. The ATSB is reliant on coroners to assist with forensic and pathology testing.

I am again grateful to the Deputy Prime Minister and Minister for Transport and Regional Services, the Hon. John Anderson, to our Parliamentary Secretary, Senator the Hon. Ron Boswell, and to the Department Secretary Mr Ken Matthews, for their support throughout the year. I also acknowledge the bipartisan support the ATSB has received for its safety work and in the course of the passage of the TSI Act.

Kym Bills

The ATSB Annual Review documents ATSB's achievements and safety activities from 1 July 2003 to 30 June 2004 and outlines its business planning for 2004-2005.

Executive Director's message

The ATSB had a busy and productive year in 2003-04 in all modes.

In its aviation activities, the ATSB released 63 investigation reports including important reports on fatal accidents at Hamilton Island, Bankstown, Moorabbin and Toowoomba and on a Saab 340 serious icing incident near Bathurst. The Bureau generated 46 air safety recommendations including those arising from the Hamilton Island investigation, on Robinson helicopter blades, and concerning the National Airspace System following a close proximity serious incident near Launceston.

The ATSB marine unit released 17 reports including on the Doric Chariot and the Star Sea Bridge accidents and also completed two reports on Sydney ferry accidents. ATSB rail outputs included an important investigation report into the Spencer Street, Melbourne 'runaway' train accident and into a level crossing accident at Aloomba in Queensland. The ATSB's twenty two 2003-04 road safety research and statistical reports included important reports on vehicle conspicuity and rural speed.

Using new 2003-04 Budget funding, the ATSB prepared and released 10 aviation research and analysis reports, developed a new rail safety investigation database (RIASIS) on time and under budget, initiated five new rail investigations on the Defined Interstate Rail Network, and established a new marine non-mandatory confidential safety reporting scheme.

During 2003-04, the Transport Safety Investigation Act 2003 (TSI Act) and Regulations applied to all new ATSB investigations in aviation, marine and interstate rail modes. Gratifyingly, there were no major problems encountered with the new legislation.

The ATSB continued to release all of its significant safety outputs to the public and hits on the ATSB website again increased to an annual rate of around eight million by the end of the financial year.

Steady progress was made with jurisdictions and stakeholders on road safety but with great challenges remaining to meet or better the 2010 target of no more than 5.6 road deaths per 100,000 population and to reduce serious injuries. A particular highlight was the release of a substantial road safety publication to mark World Health Day on 7 April 2004.

On 10 November 2003, the major ATSB aviation investigation report on maintenance problems with the Ansett Boeing 767 fleet received the Flight Safety Foundation's prestigious Cecil A. Brownlow publication award at a ceremony in Washington DC. The ATSB completed the investigation into the fatal crash of an Ilyushin IL76 aircraft near Baucau in a joint investigation on behalf of East Timor with the Australian Defence Force and in cooperation with Russian investigators. The report was released on the ATSB website after the East Timor Cabinet and senior officials had been briefed by the ATSB.

The backlog of old marine investigation reports was reduced and the number of investigations on hand at 30 June 2004 was nine compared with 19 a year earlier. Unfortunately, similar progress was not made in aviation because of other pressures and constraints, including preparation for a major audit undertaken by ICAO.

The Bureau's 2003-04 achievements, including with its additional 2003-04 Federal Budget funding for new aviation safety research, rail investigation and confidential marine reporting activities, were necessarily constrained by a 10.7 percent budget reduction applied to all groups as part of the Department's 'work out/work up' strategy. However, reflecting the Government's clear priority for the ATSB's work, the Department's Executive decided to exempt ATSB from the further round of planned Budget reductions which was required across the remainder of the Department in 2004-05. The Bureau was grateful for Federal Budget funding announced in May 2004 to ease pressures in aviation investigation and to enable replacement of the OASIS aviation safety database.

During the year the Bureau continued to liaise with and seek to improve cooperation and mutual understanding with Coroners around Australia and agreed the terms of a template memorandum of understanding (MoU) with the Coroner's representative, the Chief Magistrate of Tasmania, Mr Arnold Shott, with whom an MoU was signed in June.

A number of valued staff members retired during the year or prior to publication of this Review. I acknowledge in particular the contributions of Chris Brooks in road safety, Nick Rutherford in marine investigation and Rob Graham in leading safety investigations and work on IT systems.

I am grateful to the Deputy Prime Minister and Minister for Transport and Regional Services, the Hon. John Anderson and to the Secretary of the Department of Transport and Regional Services, Mr Ken Matthews, for their support throughout the year. It was also a pleasure working with Minister Campbell on road safety prior to his elevation to Cabinet in July 2004 and replacement by Minister Lloyd. The ATSB was again grateful for the bipartisan support it received for its safety work. The ATSB's ongoing effective role as the Australian Government's primary transport safety investigator remains reliant on both the perceptions and reality of its independence, fairness and professionalism.

Kym Bills

The ATSB Annual Review documents ATSB's achievements and safety activities from 1 July 2004 to 30 June 2005 and outlines its business planning for 2005-2006.

Executive Directors message

In 2004-05 the ATSB benefited considerably from the funding boost for aviation investigations and aviation database replacement that was provided in the May 2004 Federal Budget. During the year, the Bureau recruited and commenced training 12 extra aviation safety investigators, instigated 109 aviation occurrence investigations and released 98 aviation investigation reports, up from around 60 in recent years. High profile aviation safety investigation reports released in 2004-05 included reports on investigations into a fatal Cessna C404 aircraft accident at Jandakot Airport WA, a fatal Emergency Medical Services (EMS) helicopter accident near Mackay, Qld and a Boeing 737 terrain proximity warning near Canberra. The Bureau also released nine aviation safety research reports.

During 2004-05, the ATSB issued 19 aviation safety recommendations and two safety advisory notices and successfully negotiated valuable safety actions by regulators, operators, manufacturers and other safety stakeholders. For example, following ATSB recommendations from the investigation into the EMS helicopter accident, the Queensland Emergency Services Department is improving standards and support for Community Helicopter Providers including requirements for night Visual Flight Rules (VFR) flights and the helicopter operator is requiring and training all pilots to Command Instrument Rating standard. The Bureau also completed Stage 1 of the Safety Investigation Information Management System (SIIMS) aviation database replacement project, which involved developing ATSB user requirements and the trial of software tools to support the improved management of safety investigations.

The ATSBs marine achievements in 2004-05 included 11 marine investigation reports including on the grounding of the cruise liner Astor, and the fatal collision between the bulk carrier Asian Nova and the fishing vessel Sassenach. The ATSB also undertook an extensive education campaign within the fishing industry on commercial fishing vessel safety.

In November 2004 the ATSB established an Adelaide regional office as a base for its rail team leader and two other rail investigators. Two rail investigators are based in the ATSBs Brisbane office and one in the Canberra central office. During 2004-05, the Bureaus rail safety investigation team initiated seven investigations on the Defined Interstate Rail Network (DIRN) under the Transport Safety Investigations Act 2003 (TSI Act) and released the first TSI Act rail investigation reports on freight train derailments at Ararat, Victoria and Bates, South Australia. The ATSB also completed a rail investigation report under Victorian legislation into the derailment and subsequent collision at Chiltern between a freight train and a passenger train.

On road safety, the ATSB is coordinating the Australian Government involvement, in partnership with the NSW and Victorian governments and private sector organisations, in a large-scale trial of a best-practice education programme for novice drivers. During 2004-05, the Bureau released 32 road safety research and statistical reports, including a research report on road texture and crash risk and a survey of community attitudes. Steady progress was also made with road safety jurisdictions and stakeholders, but with substantial challenges remaining to meet or better the 2010 target of no more than 5.6 road deaths per 100,000 population.

The October 2004 International Civil Aviation Organization (ICAO) report on ICAOs May/June 2004 audit of the ATSB expressed high satisfaction with Australia's legislative, organisational and training framework for aviation safety investigation and the professional and efficient conduct of the ATSB investigations reviewed in detail. As expected, the audit team did make a number of recommendations for improvement against which the ATSB has undertaken corrective actions.

Following the 15-fatality Metroliner aircraft accident near Lockhart River, Queensland, in May 2005, the Bureau commenced its major investigation into the causes of this tragedy and released a preliminary factual report in June 2005. In November 2004 the Queensland Government asked the ATSB to chair a joint Queensland Transport investigation into the derailment of the Cairns Tilt Train north of Bundaberg, which injured a significant number of the 157 passengers and crew. The Queensland Minister for Transport released an interim report on this derailment on 16 February 2005.

The Bureau is continuing its commitment to training its investigators through the Diploma of Transport Safety Investigation course. In 2004-05, fifteen staff completed the TSI Diploma and a further 30 are progressing through the course.

During the year the Bureau signed a number of Memoranda of Understanding (MOUs) including with the Civil Aviation Safety Authority (CASA), the Australian Maritime Safety Authority (AMSA), the Victorian Rail Safety Regulator and with transport safety bodies in Indonesia and South Korea.

The ATSB continued to release all of its significant safety outputs to the public. Hits on the ATSB website www.atsb.gov.au amounted to around sixteen million.

A number of valued staff members retired during the year or prior to publication of this Review. I note in particular the contribution of Jon Henchy in Transport Safety Statistics. From early June 2005 I was off-line assisting the Rt Hon Sir John Wheeler with a review of Airport Security and Policing and Joe Motha has acted as ATSB Executive Director in addition to his normal duties with great professionalism and dedication which I wish to acknowledge with thanks.

I am grateful to the former Deputy Prime Minister and Minister for Transport and Regional Services, the Hon. John Anderson MP, the Minister for Local Government, Territories and Roads, the Hon. Jim Lloyd MP, and to the Secretaries of the Department of Transport and Regional Services, Mr Ken Matthews AO and Mr Mike Taylor for their support throughout the year. We look forward to working with the new Minister for Transport and Regional Services, the Hon. Warren Truss MP in 200506. The ATSB was again grateful for the bipartisan support it received for its safety work. The ATSBs ongoing effectiveness as the Australian Governments primary transport safety investigator remains reliant on both the perceptions and reality of its independence, fairness and professionalism.

Kym Bills

The ATSB Annual Review 2002 documents ATSB's achievements and safety activities from 1 July 2001 to 30 June 2002 and outlines its business planning for 2002-2003.

Executive Directors message

The Australian Transport Safety Bureau has made significant progress since it began on 1 July 1999 as an operationally independent body within the Commonwealth Department of Transport and Regional Services (DOTARS).

During 2001-02, the ATSB assisted the Minister for Transport and Regional Services to develop new legislation that would enable the Bureau to investigate rail accidents on the increasingly important interstate system. The legislation also updates and harmonises the Bureaus aviation and marine investigative powers. Introduced into parliament on 20 June 2002, the Transport Safety Investigation Bill 2002 (TSI Bill) passed the House of Representatives with bipartisan support on 24 September and is currently before the Senate. The Bureau is also involved with the drafting of associated Regulations and proposed memoranda of understanding with key stakeholders.

The Bureau revised its investigator work-level standards and developed an internal competency-based Diploma in Transport Safety Investigation, for which national tertiary accreditation has been granted for five years. The Diploma will help validate that ATSB investigators have reached a minimum competency standard before assuming more senior responsibilities.

The federal industry minister asked the ATSB to investigate, under the Space Activities Act, an accident involving the first HyShot rocket launch at Woomera. The launch was to test a University of Queensland scramjet, a world-leading project in the race for faster passenger transport. The Bureaus investigation of the October 2001 launch and its final report and recommendations led to important changes before a reportedly highly successful second launch.

The ATSB has continued to monitor and report on road safety progress under the National Road Safety Strategy framework approved by ministers of the Australian Transport Council (ATC). It has worked closely with state and territory transport agencies, and other major stakeholders, through the National Road Safety Strategy Panel. Toward the end of the financial year, the Bureau, aided by a panel of distinguished road safety experts, formed a task force to develop an Action Plan for 2003 and 2004. The national road fatality rate, which stood at nine deaths per 100 000 population in calendar year 2001, has plateaued since about 1997 and the new Action Plan will seek to substantially cut the road toll. ATC approved the Plan on 8 November 2002.

The Parliamentary Secretary, Senator the Hon. Ron Boswell, released several ATSB research reports and a number of other road safety publications throughout the year. Two important studies concerned speed risks. ATSB research findings on the links between travel speed and road trauma have been widely cited in policy papers produced by other agencies (both in Australia and overseas) and have supported a number of major public education campaigns on speed. The Bureau also released reports on motorcycle fatalities and on driveway deaths. ATSB researchers have a special interest in fatigue issues and are working to improve national injury data as well as data on heavy-vehicle safety.

The ATSB continued to participate in rail-safety investigations at the invitation of state governments. Since 1999, the Bureau has undertaken or taken part in nine investigations. Most of these were in Victoria, but others have involved WA, NSW, Queensland and SA. Investigations have brought about important safety changes, including to operational practices and to legislation. In cooperation with state rail regulators, the Bureau has also created a national rail occurrence database with a concise set of key statistical rail safety indicators for the calendar year 2001. Ongoing discussions with state rail regulators are directed to extending the databases coverage of safety occurrences, harmonising definitions and incorporating pre-2001 data.

In 2001-02, marine reports released included investigations of groundings and collisions between ships and fishing vessels. Recognising the international nature of the shipping industry, the ATSB has continued to actively support the work of the International Maritime Organization, where it has addressed topics such as lifeboat safety and vessel fires, and to provide marine investigation and safety training. Captain Kit Filor continued as chair of the Marine Accidents International Investigators Forum (MAIIF).

The ATSB released 118 final air safety investigation reports in the past financial year thereby reducing its investigation report backlog from 125 to 90. Major reports included:

• the Whyalla Airlines VH-MZK Piper Chieftain accident with eight fatalities
• the Beech Super King Air 200 VH-SKC ghost flight fatal accident which followed the incapacitation of the pilot and seven passengers
• a serious incident involving loss of control during one engine inoperative training in a Beech 1900D airliner.

The Bureau continued to investigate maintenance problems involving Ansett's 767 fleet and Class A aircraft, as well as a fatal accident involving the WA Police Airwing at Newman. It also helped the Aviation Safety Council of Taiwan investigate a major Singapore Airlines SQ006 747 fatal accident. The President of Taiwan acknowledged the Bureaus contribution when he opened the International Society of Air Safety Investigators (ISASI) forum in October 2002. Aviation outputs also included CAIR reports, recommendations and safety notices, as well as articles in magazines such as Flight Safety Australia. The Bureau further developed its website www.atsb.gov.au and now receives more than four million hits each year.

When the Secretary reorganised the Department in January 2002, the Bureaus previous federal Black Spot and vehicle recall functions transferred to more appropriate divisions within DOTARS. I thank the staff involved for their contributions to the ATSB. I particularly wish to acknowledge Adrian Beresford-Wylie, who left the Bureau for a senior DOTARS position in September 2002. As a branch head, Adrian made a great contribution to the Bureau and to Australian road safety. I am pleased to welcome Joe Motha who has taken on Adrians former role.

I am grateful to the Deputy Prime Minister and Minister for Transport and Regional Services, the Hon. John Anderson, to our Parliamentary Secretary, Senator the Hon. Ron Boswell, and to the Department Secretary Mr Ken Matthews, for their support throughout the year. The ATSB is passionate about its role in contributing to safe transport and on behalf of the ATSBs hardworking staff, I affirm that the Bureau looks forward to meeting the challenges of 2002-03 and beyond in all four transport modes.

Kym Bills