Review by 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, autothrust 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.

Type:	Annual Report
Publication Date:	22/12/2011
ISBN:	978-1-74251-086-6
ISSN:	1838-2967