This section describes the ATSB’s performance against the deliverables set out on page 21 of the ATSB Corporate Plan 2019–20.
To meet its objective for improved transport safety, the ATSB has committed to the following safety data recording, analysis and research deliverables:
- Mature the ATSB’s data analysis tools and techniques to enhance the ATSB’s proactive capability for determining safety hazards and risks to be used in making assessments about occurrences to investigate, and safety studies to commence.
- Assess, classify and publish summaries of accidents and incident occurrences received. Details of occurrences being investigated are published within one working day. Summaries of aviation occurrences are ready to be published in the public online database within 10 working days of receipt.
- Assess confidential reports for clarity, completeness and significance for transport safety and, where appropriate, advise within six weeks any responsible party in a position to take safety action in response to the safety concern.
- Publish five statistical and trend monitoring publications (including the Aviation Occurrence Statistics Report).
In 2019–20, the ATSB continued to analyse occurrence data held in its aviation safety occurrence database as part of Australia’s international obligation to determine if preventative safety measures are required.
In addition to these deliverables, the ATSB continued to support active aviation occurrence investigations. During 2019–20, the ATSB completed significant data analysis for most aviation occurrence investigations. This work helped to determine the investigation scope, inform investigation conclusions and safety issue risk assessments, and document past occurrences of similar incidents.
Data analysis capability
The ATSB continued a data analysis capability expansion program in 2019–20 by:
- initiating the building of a data repository (to be completed in 2020–21) to house copies of all databases used by the ATSB
- participating in feasibility planning with the Bureau of Infrastructure, Transport and Regional Economics for a shared multi-agency aviation data warehouse
- expanding the number of staff trained in Structured Query Language (SQL) and other programs.
Data and recorder recovery
The ATSB’s data and recorder recovery staff maintain support and readiness for the recovery and download of recorded data from a variety of damaged and undamaged sources across the aviation, rail and marine transport modes.
Over this reporting period, the ATSB continued to support external agencies by providing assistance to Recreational Aviation Australia and the Civil Aviation Authority of the Philippines – Aircraft Accident Investigation and Inquiry Board to recover data from damaged recording devices.
Material failure analysis
The ATSB possesses expertise and specialised facilities to enable the detailed examination of physical evidence, allowing for significant insights into the causes of factors of transport safety occurrences. During 2019–20, transport safety investigators with engineering specialist backgrounds have provided technical input and analysis across a variety of investigations. A selection of tasks included:
- Determination of the existence of pre-existing cracking in the exhaust manifold from the de Havilland DHC-2 Beaver aircraft involved in the collision with water in Jerusalem Bay, NSW (AO-2017-118). The findings prompted the ATSB’s release of a safety advisory notice, reinforcing the importance of thorough inspection and maintenance of exhaust systems, and ensuring firewall integrity to limit the risk of carbon monoxide exposure.
- Analysis of a hydraulic cut-off switch from the collision with terrain involving the Airbus Helicopters AS350BA Squirrel, at Hobart Airport, Tasmania (AO-2017-109). Worn components in the switch had the potential to cause intermittent operation and delays in the restoration of the hydraulics system.
- Investigation of a fan blade failure from the engine of an Airbus A330 near Carnarvon, WA (AO-2017-066).
- Engine and propeller examination in support of the ongoing investigation into the Lockheed C-130 firebombing accident, near Cooma, NSW (AO-2020-007).
- Examination of components from the ongoing investigation into a landing gear failure involving a GippsAero GA-8 Airvan on Fraser Island, QLD (AO-2019-045).
- Examination of a rescue hoist cable from an Airbus Helicopters AS 350 B3, which found that improper stowage of the hook assembly was likely contributing to accelerated wear. This resulted the publication of an ATSB safety advisory notice to all helicopter operators involved in winching operations (AO-2020-013-SAN-001).
The ATSB’s target for assessing, classifying and publishing summaries of accidents and incidents is:
- one day for occurrences being investigated (all modes)
- 10 days for summaries of other incidents (aviation).
Of 78 occurrences investigated, 44 (56 per cent) were processed with summaries published on the ATSB website within one working day of the start of the investigation.
In 2019–20, 35 per cent of aviation occurrence notifications were processed and ready for publication within 10 working days. The average time for publishing was 25 working days.
In 2019–20, the ATSB’s Confidential Reporting Scheme (REPCON) received 150 notifications (of which 62 were classified as REPCONs). Of these 150 notifications, 91 concerned aviation (35 REPCONs), 54 concerned rail (24 REPCONs) and five concerned marine (three REPCONs).
Of the 150 notifications, 39 REPCONs were subsequently withdrawn by the reporter or were duplicate reports of the same concern (17 in aviation, 20 in rail, and two in marine).
Of the 29 REPCON reports completed in 2019–20, 19 (66 per cent) resulted in safety action by stakeholders.
The following summaries provide examples of safety concerns that were raised, along with the safety action taken after the concerns were reported through REPCON. Some information has been redacted to preserve confidentiality.
The reporter raised a safety concern regarding the PAPI at [Location] aerodrome. The reporter advised that at that time of the year, the wind favours runway 26 for instrument approaches at [Location]. The RNAV instrument approach to this runway has a slope of 3.2 degrees. Airservices Australia has indicated that the 3.2 degree slope is clear of obstacles and safe to use; however the PAPI is set at 4 degrees, which results in four red lights throughout the entire approach. The reporter believed this was a safety issue and the PAPI needed to be immediately aligned with the approach slope or be switched off. Either way a false or nil PAPI is contrary to the appropriate operations for slope indications for RPT aircraft. The reporter advised that they had been requesting a resolution to the issue for some years and believed it necessary to report to ensure it was rectified in the interests of conforming to regulations and safety. As a result of the REPCON, the regulator advised that based on the information received, the aerodrome operator was contacted and advised that PAPI needs to be realigned to the standard 3 degree slope with the lowest on-slope observed colour transition at 2d 48’. This is a significant change that will need to be completed by theodolite survey in accordance with the commissioning guidance included in CAAP 89T-1. Given the high threshold crossing height for this runway approach it appeared that the light projectors were originally positioned at a distance along the runway to suit a 3 degree slope and were subsequently elevated to 4 degrees after installation. Therefore, they should just be able to adjust the projectors down. The adjustment will need to be assessed and completed by a suitably competent person. In the short term a NOTAM was raised to communicate that the PAPI is not aligned with the approach procedures. Given that there are no RPT jet services the PAPI could also be removed from service, unless the airline prefers the guidance even though it is set too steep.
A previous REPCON was re-opened following the reporter’s concerns that previously agreed safety actions had not been actioned.
The concern related to the safety of cruise ship operations at [Location] operating without tugs in operation or on standby. The reporter was concerned that the risk assessment process to preclude the use of tugboats was insufficient and did not take into account any human factor error, which is documented to be a cause or contributing factor in 70 per cent of marine incidents. The reporter was further concerned that there was no provision for pilots to drop an anchor at [Location] due to risk of damaging infrastructure. The operator initially advised that the procedures for cruise ships entering and departing [Location] would be reviewed and risk assessed, and the regulator agreed to review those procedures. However, the reporter advised that this process had not yet occurred despite ample time to do so. As a result, the ATSB Marine Commissioner and Chief Commissioner met with the [Location] Harbour Master to discuss the concerns. The Port Authority offered to provide the ATSB with the draft independent report for review, which the ATSB is currently reviewing.
The reporter raised a safety concern regarding proposed changes to policy that would see all in-field protection for R1 and R2 track machines operating within a Track Occupancy Authority removed. The reporter advised that the current procedures stated that in-field protection, rail traffic signals (detonators) and/or red boards, must be in place at the limits of the Track Occupancy Authority, where the track is obstructed or otherwise made unsafe for rail traffic. The proposed removal of all in-field protection enables track machines that are working clear of a set of points to potentially reach a set of points without the machine operator receiving any prior warning. A train travelling at road speed could potentially reach the same set of points at the same time, resulting in a train to train collision. As a result of the REPCON, the operator advised that they had developed a Safety Notice, which clarifies the requirements for placing stop signs to delineate the limits of the work on track authority. This notice is also consistent with the reporting party’s mentioned local procedure. The operator re-affirmed that the current requirements include the Protection Officer clearly communicating the worksite limits to the operators of track vehicles, and making an assessment to determine if visual delineation of the limits is required. The Safety Notice mandates that, “Where the TOA limits are not defined by facing signals (e.g. clear of a set of points) there is a risk that the track vehicles could foul the adjacent line or depart from the TOA limits without authority.”
In 2019–20, the ATSB published two statistical reports:
These reports are available on the ATSB website at www.atsb.gov.au.