Research and Analysis Report

The Robinson R22 helicopter is the most common model of rotary-wing aircraft on the Australian register and has been a popular choice for private operations, flying training and various types of aerial work activity. The R22 has a relatively good safety record compared with other light piston-engine helicopters in Australia based on activity levels.

The R22 is also the favoured type for aerial stock mustering operations - a uniquely Australian application that supports the local beef cattle industry. Despite its popularity in this type of work, little was known about the helicopter's suitability for the task. Like other helicopters on the Australian register, the R22 received its initial airworthiness certification in its country of manufacture (United States). The spectrum of manoeuvres conducted in aerial stock mustering did not form part of the flight profile used when the helicopter type received its certification.

In 2004 the ATSB commissioned AeroStructures, an Australian engineering company, to undertake a study of forces acting on an R22 engaged in aerial mustering operations. AeroStructures Report:

Their study offers some useful data on R22 flight profiles in aerial mustering operations, and compares these with the flight profiles used by Robinson Helicopter Company when the helicopter was initially certified.

The AeroStructures testing showed that mustering operations can involve large and sudden power changes that apply very high loads on the helicopter's drive system, and these may exceed the limits set during the certification process. Their report highlights the importance of handling technique, and especially good engine management.

This aim of the study was to provide objective data to inform fatigue risk-management processes by determining the quantity and quality of sleep obtained by airline pilots during transcontinental back of clock operations, and any changes to subjective fatigue and neurobehavioral performance during these sectors. Typical transcontinental back of clock route pairings involve a departure close to midnight Perth local time, with a dawn arrival into an East-coast city such as Melbourne, Sydney or Brisbane. In many instances this first sector is followed by a second sector to another east-coast destination, with sign-off at approximately 0900 Eastern Standard Time. Data were collected by participants during a two-week period of a normal rostered flying for an airline. During each of the 14 days of data collection, participants were required to undertake the following:

1. Wear an activity monitor wristwatch 7 days prior to, and 6 days after, a transcontinental back of clock flight;
2. complete sleep and duty diaries, which record time of sleep, subjective alertness, and time of duty; and
3. complete a simple 5-minute Psychomotor Vigilance Task (reaction time task) during the cruise of each sector, and three times on non-flying days.

The results of this study suggest that Australian transcontinental back of clock operations, as operated by the airline involved in this study, differed significantly from a baseline sample of daytime duty periods in a number of important areas with respect to prior sleep, neurobehavioral performance, and subjective fatigue. While there were some significant differences in sleep and subjective fatigue as a function of a single transcontinental sector of back of clock flying, these differences were, on average, of a magnitude that was unlikely to impact on flight crew performance and overall safety. However, when a primary transcontinental sector is followed by an additional east-coast sector, there is evidence of reduced prior sleep, impaired neurobehavioral performance, and high levels of subjective fatigue.

Each year the United States' Aircraft Owner's and Pilots Association (AOPA) Air Safety Foundation releases a report summarising the accident trends and factors for general aviation (GA) for the previous calendar year. The Nall Report has established itself as one of the aviation community's benchmark reports and its release is anticipated across the industry. The report provides essential data in an easy-to-read format, giving a broad overview of the state of general aviation and safety trends in the US.

As part of the Australian Transport Safety Bureau's (ATSB) mission to enhance public awareness of aviation safety, the Australian Aviation Safety in Review - 2007 has been developed to provide a readily accessible analysis of the Australian aviation sector, with a strong focus on safety trends. Unlike the Nall Report, this publication covers all major categories of aircraft operations, from Regular Public Transport (RPT) to general aviation, and even some information about sports aviation.

Additionally, some demographic data on Australian aviation is provided in order to measure the levels of aviation activity in Australia, and provide a context within which to examine the accident trends. Accident rates are presented both in terms of the number of accidents and as rates per 100,000 hours, to enable comparison between operational categories. The latest year for which flying hours are available is 2005. Accordingly, this inaugural edition of the Australian Aviation Safety in Review - 2007 covers the calendar years 2001 to 2005, offering insights and information about key trends and emerging issues.

The ATSB intends to release this report on a regular basis as a means of informing both the aviation community and the wider public about Australian aviation accident and activity trends.

Regional airline operations globally have expanded over the past decade for various reasons, including filling gaps left by legacy carriers who have reduced services on unprofitable routes, opportunities provided through other cost based market rationalisations, and the introduction of new and more capable regional type aircraft. Very little formal research has been done in Australia or overseas to assist with the development of safety models and tools for regional airline operations. Regional Express (REX) is a relatively new airline that was created by merging two separate and culturally different airline entities. After a post start-up initial settling in period, REX needed a new tool to further develop safety-based auditing for its newly combined flight operations department. The Line Operations Safety Audit (LOSA) offered through the University of Texas LOSA Collaborative, provided an effective tool for this purpose. Around the time REX was reviewing its need in this area, the LOSA Collaborative was confirming an interest in conducting research with regional airlines. The LOSA Collaborative wished to obtain data from regional airlines to add to its LOSA Archive database in order to move toward making the database more representative and the LOSA tools more relevant for use in the regional airline environment. The LOSA Collaborative set out to attract three regional airline participants to add their data through the LOSA process. Regional Express was successful in attracting funding under the Australian Transport Safety Bureaus Aviation Safety Research Grants Program to undertake the LOSA process. Completion of this project has added to the expansion of the LOSA database to include regional airline data. This report describes the LOSA process as it applies within the regional airline context of REX and the reported outcome types specific to the LOSA methodology, process, and tools. Regional Express is one of the first regional airlines globally to participate in a LOSA program.

Maintenance incidents contribute to a significant proportion of worldwide commercial jet accidents, yet until recently, little was known of the nature of maintenance incidents and the factors which promote them.

In face-to-face interviews, maintenance technicians were asked to report examples of maintenance incidents which they had experienced first-hand. Eighty-six incident reports were recorded.

Human factors were involved in most of the reported incidents, with workers on duty between the hours of 0200 and 0400 having a greater chance of having an incident than workers on duty at other times of the 24-hour clock. The frequency of incidents increased as the shift progressed up to the second-last hour, after which the frequency of incidents diminished.

For those incidents which had the potential to affect the airworthiness of an aircraft, difficulties with procedures emerged as the most significant factor. This included misunderstandings and ignorance of procedures.

For those incidents which had the potential to affect the health and safety of workers, difficulties with tools and equipment emerged as the most frequent factor.

The majority of the human errors involved in incidents were rule-based mistakes, many related to mistaken assumptions. Absent-minded slips and lapses were involved in approximately one-third of the incidents.

The final section of the report contains suggested safety actions, intended firstly to reduce the frequency of human error and maintenance incidents and secondly, to reduce the consequences of any such errors which do occur.

Human error is recognised as an important issue in fields as diverse as medicine, mining and shipping, and to some extent aviation.

Although the human element has long been recognised as important in the cockpit, its role in aircraft maintenance has been largely overlooked.

According to Boeing figures 12% of major aircraft accidents involve maintenance, and 50% of flight delays in the US are caused by maintenance errors.

In response to a worldwide lack of information on the issue, in late 1998 the Bureau distributed a safety survey to all licensed aircraft maintenance engineers in Australia.

This survey was the first such study undertaken anywhere in the world.

In addition to collecting incident reports, part of the survey used a technique pioneered by road safety researchers in the UK, where recipients were asked to report minor errors and shortcuts.

The focus was on learning how common these events are relative to one another, rather than obtaining precise event frequency information. In that regard there was no specific time frame specified in the survey form in which the event could have occurred.

Most of the errors reported by the respondents constitute 'near misses'. However, it is possible to anticipate how more serious events could occur by gathering this information.

The ATSB considers that the issues identified in the survey are not specific to Australia but will be of use to safety agencies around the world.

Based on early information from the survey the Bureau previously published in Asia-Pacific Air Safety articles that identified a number of recommendations:

1. the need for refresher training for aircraft maintenance engineers
2. the need to remove barriers which discourage aircraft maintenance engineers from reporting incidents
3. the need for fatigue management programs
4. human factors training for management and engineers, and
5. minimisation of the simultaneous disturbance of multiple or parallel systems, such as both engines on twin-engine aircraft.

The recent article on the survey on the ATSB Supplement to Flight Safety Australia March-April 2000 also included advice directed to aircraft maintenance engineers concerning memory lapses, pressure, fatigue and coordination difficulties.

The survey is part of a broader study of aircraft maintenance operations, which is anticipated, will lead to identification of targeted safety measures.

A review of existing Commonwealth, State and Territory legislation relating to the transport of dangerous goods by rail, was undertaken. The review provides an overview of the status, coverage and adequacy of existing rail dangerous goods transport legislation. The review also examines options for the development of a nationally uniform regulatory regime for rail dangerous goods transport operations. Issues relating to inter-modal harmony with the road transport sector, and legislative options to achieve uniformity are also discussed. The review concludes that a nationally uniform rail dangerous goods regulatory regime, harmonised with the road transport sector, should be given a high priority due to safety, transport efficiency and economic reasons.

The details of 75 fatal aeroplane accidents were extracted from the BASI database. The largest proportion (36%) of the accidents occurred on private/business flights. The three most frequent first occurrences in accidents were loss of control; collision with terrain (control unknown); and wirestrike. Most accidents had more than one contributing factor. Over 70% of the accidents involved pilot factors. The most common pilot factors related to poor judgement and decision making.

In recent years, BASI has recognised that while pilot factors are of great importance, accidents frequently have their origins in systemic or organisational failings.

With the creation of the ATSB in July 1999, followed by the enactment of the Transport Safety Investigation Act (TSI Act) in 2003, Australia had for the first time a national body with a mandate for professional and independent rail safety investigations.

In its relatively short existence, the ATSB's rail safety unit has had a significant influence on rail safety in Australia. In particular, it has been instrumental in fostering an approach that emphasises the importance of system safety, rather than just focusing on the mistakes of operational personnel.

Other notable achievements of the ATSB in rail investigations have included raising awareness within the rail industry of the importance of modern health and safety standards for operational personnel, and highlighting specific accident types. These include accidents due to poor communications, signalling difficulties, derailments such as through dynamic track and rolling stock interactions, fatigue, and level crossing collisions.

This report analyses birdstrikes reported to the Australian Transport Safety Bureau between 2002 and 2006. In Australia, over the last five years, the number of birdstrike occurrences reported annually to the Australian Transport Safety Bureau (ATSB) has risen from approximately 750 in 2002 to 1,200 in 2006. The report includes bird and bat strikes that occurred in Australian territory involving VH- and overseas registered aircraft. It excludes strikes involving non VH-registered Australian aircraft and those involving VH-registered aircraft that occurred overseas. Birdstrikes were analysed by year, month, phase of flight, type of operation, record source, effect on flight, time, aircraft damage, injuries, the nature of occurrence reports, flight disruption, aircraft movements, aircraft size, ingestion, bird size, species, and location. Location data are presented for major aerodromes, General Aviation Airport Procedures aerodromes and regional aerodromes. The report tables birdstrikes and aircraft movements, as well as species struck and species causing damage.

Birdstrike reporting was found to have almost doubled over the reporting period. There have been three injuries, but no fatalities. Around seven per cent of birdstrike events resulted in damage, and double-engine ingestion was recorded for eight of 5103 birdstrike occurrences. Birdstrike events vary by location, and rates of birdstrike events at aerodromes are only indicators of the effectiveness of control measures.