Research and Analysis Report

On 3 July 2009, the Australian Transport Safety Bureau (ATSB) was notified that a SAAB Aircraft Company 340B (SAAB), registered VH-ZLW, had commenced its take-off roll along the runway 25 left edge lights at Sydney Kingsford Smith Airport, New South Wales. This was one of three occurrences over the previous 2 years that involved aircraft commencing take-off on the runway edge lighting.

In addition, within the previous 2 years the ATSB investigated two other occurrences involving pilot misidentification of runway alignment cues or lack of those cues during take-off. All five Australian misaligned take-off and landing occurrences involved aircraft with weights greater than 5,700kg and three of the six occurrences involved scheduled regular passenger transport (RPT) operations. The remaining two occurrences involved charter operations.

This research investigation examined each of these occurrences and relevant international occurrences to identify the common factors associated with misaligned take-off and landing occurrences.

After reviewing the Australian and international occurrences, eight common factors were identified that increased the risk of a misaligned take-off or landing occurrence. The factors included: distraction or divided attention of the flight crew; confusing runway layout; displaced threshold or intersection departure; poor visibility or weather; air traffic control clearance/s issued during runway entry; no runway centreline lighting; flight crew fatigue; and recessed runway edge lighting.

A significant proportion of all occurrences reported to the Australian Transport Safety Bureau (ATSB) involve aircraft striking wildlife, especially birds. This report provides aviation birdstrike and animal strike occurrence data for the period 1 January 2002 to 31 December 2009. It also describes the results of an ATSB survey of aerodromes concerning current wildlife control measures.

Reported birdstrikes have been generally increasing since 2002. In 2009, there were 1,340 birdstrikes reported to the ATSB. For high-capacity aircraft operations, reported birdstrikes have doubled from 2002 to 2009. However, taking into account an increase in aircraft movements, this increase is modest and is probably accounted for by a generally improving reporting culture within this time.

Birdstrikes have increased for the period of study in every Australian state and territory. Queensland, New South Wales, the Northern Territory and Western Australia have the highest birdstrike rates. The higher birdstrike numbers for Queensland and the Northern Territory may be related to bird populations within the tropics, while New South Wales has the highest number of major aerodrome aircraft movements in Australia.

Most birdstrikes occur within the confines of aerodromes (less than 5 km). Major and regional towered aerodromes had significantly higher rates of reported birdstrikes than General Aviation Airport Procedures (GAAP) aerodromes, and had considerably increasing rates from 2002 to 2009. GAAP aerodrome birdstrike rates do not appear to have changed.

Engine ingestion makes up 11 per cent of all birdstrike occurrences in high-capacity air transport for the 8- year period, and the highest number of damaging birdstrikes occurs in high-capacity air transport. Birdstrikes causing multiple parts damaged were not common throughout the period. General aviation had the highest proportion of damaging birdstrikes, with almost 24 per cent of birdstrikes causing damage. Aeroplane wings and helicopter rotor blades are the most commonly damaged aircraft components across all operational types, particularly in general aviation. There have been eight occurrences from the period of 2002-2009 that have resulted in serious aircraft damage, and four that have resulted in injury.

The most common types of birds struck by aircraft were lapwings/plovers, bats/flying foxes, galahs, and kites. Not surprisingly, larger birds were more likely to result in aircraft damage.

Animal strikes were relatively rare. High-capacity air transport had the highest average with 11.5 animal strikes per year, with general aviation having the second highest average with 9.3 animal strikes per year. The most common animals involved in strikes were hares/rabbits, kangaroos, wallabies, and foxes/dogs. Damaging strikes mostly involved kangaroos, wallabies and livestock.

Bird hazard control at aerodromes was found to be mostly related to the control of grass height (short or long) and growing specific plants or grass, and the daily or weekly use or auditory deterrents, especially car horns and shotguns.

The aviation industry has been slow to acknowledge the risks associated with ground operations. While most occurrences on airport aprons and taxiways do not have consequences in terms of loss of life, they are often associated with aircraft damage, delays to passengers and avoidable financial costs to industry. The focus of this report is to examine ground occurrences involving high-capacity aircraft operations.

This report examines occurrences involving ground operations and foreign object debris that occur at Australian airports which receive high-capacity aircraft. It uses occurrence and investigation data reported to the Australian Transport Safety Bureau to create a picture of ground occurrences. This picture begins when an aircraft is being prepared for takeoff and ends when passengers and crew have disembarked from the aircraft. It explores contributing factors associated with each type of occurrence, with the objective of providing some insight into what happened and why various events occurred. The key to preventing ground occurrences appears to revolve around ensuring effective communication between pilots, ground crews and air traffic services through a process of checks and balances.

In late 1992, the Bureau of Air Safety Investigation (BASI) noted a large increase in violations of controlled airspace (VCAs). Whereas in most of 1991, there had been around 25 such incidents per month, in December 1991 there were 42 of these incidents and throughout 1992 BASI received an increasing number of VCA notifications. The increase in VCAs was of particular concern as it may have reflected difficulties with the implementation of the Airspace Management and Air Traffic Services (AMATS) changes to Australian airspace. A VCA is a serious incident because of the risk of a collision between the intruder and an aircraft under air traffic control (ATC).

In 1992 a study (RP/92/10) was performed to examine VCA occurrences. The report found that VCAs had increased sharply following the introduction of the AMATS system in late 1991.

The aim of this report is to provide updated information on the VCA situation. As an update on the 1992 VCA report, the most recent six-month period, January to June 1994, will be examined.

The status of commercial passenger operations in turbine powered single engine aeroplanes is presently under review by the civil aviation regulatory authorities of several nations. In this information paper BASI offers no argument for or against the introduction of such operations.

Present regulations on commercial passenger carriage were developed prior to the availability of the turboprop engines which are now in operation.

The Bureau of Air Safety Investigation recently conducted research into the rates of G onset and G levels experienced by a light aircraft pilot during normal aerobatics. The objective was to relate data obtained from the research to other data available from military authorities, in order to evaluate the possibility or otherwise of a light aircraft pilot sustaining G-induced loss of consciousness (G-LOC) during aerobatics.

MTAF procedures were introduced in Australia with the AMATS changes of 12 December 1991. The MTAF procedure applies at specified aerodromes. It depends on pilots making mandatory radio calls, hearing calls from other aircraft, assessing this traffic information for potential conflict, and responding appropriately with radio communication and avoiding action if necessary.

The MTAF procedure is designed to alert aircraft to all other air traffic in a designated area surrounding a particular aerodrome. The procedure mandates certain radio broadcasts and responses in these areas, and the pilots are then responsible for arranging their own separation.

In March 1993 BASI was informed that airline pilots had considerable concerns over the safety of RPT operations in MTAF areas. Reports stated that "Since the inception of MTAFs, [pilots] are experiencing conflict situations with unannounced, unalerted traffic, on a daily basis. This is resulting in numerous instances of immediate evasive action having to be initiated by aircraft operated within MTAFs".

This report was commissioned by the Bureau of Air Safety Investigation (BASI) to investigate the system of Notices to Airmen (NOTAM) following statements from some airline flight crews that current NOTAM presentation is not optimised to meet their needs. Pilots had stated that:

• Some NOTAM are not clearly written,
• The NOTAM format can be difficult to decipher,
• There is too much irrelevant information provided.

This information paper reviews the Bureau's policy on testing for drugs and alcohol, attempts to assess the prevalence of drugs and alcohol in aviation accidents and incidents, and discusses the adequacy of the present policy. The policies of Canada, the United Kingdom, and the United States are also outlined.