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Published by the Australian Transport Safety Bureau


ISBN: 978-1-74251-327-0
ISSN : 1838-2967

© Commonwealth of Australia 2020

Apart from the Coat of Arms, the ATSB logo, photos and graphics in which a third party has copyright, this work is licensed under the Creative Commons Attribution 3.0 Australia license. To view a copy of this license visit creativecommons.org/licenses/by/3.0/au

The Australian Transport Safety Bureau asserts the right to be recognised as the author of the original material in the following manner:

© Commonwealth of Australia 2020
Australian Transport Safety Bureau

Enquiries regarding this license and any use of this document are welcome at:
Australian Transport Safety Bureau
PO Box 967
Civic Square ACT 2608

Email: atsbinfo [at] atsb.gov.au

A copy of this report is available on the ATSB website: www.atsb.gov.au

Specific acknowledgements for the use of data, photographs and other materials are included throughout this report. Where the source of any material is not specifically named, ATSB is the originator.