In addition to independent 'no blame'
investigation of transport accidents and other safety occurrences,
the ATSB contributes to improved transport safety in Australia
through:
• safety data recording, analysis
and research; and
• fostering safety awareness, knowledge and
action.
Awareness and understanding of transport safety issues is
increased through a range of activities including consultation,
education, and the promulgation of research and investigation
findings and recommendations. These contribute to the national and
international body of safety knowledge and foster action for the
improvement of safety systems and operations.
As part of this commitment, the ATSB will publish its safety
research program for the financial year including a list of all
active and proposed safety research projects. This program may be
updated during the financial year to reflect changes to priorities
and scope.
_________
Research Investigations & Data Analysis Program
2010-2012
Safety in the vicinity of non-towered
aerodromes
Most aerodromes in Australia are located in uncontrolled
airspace and do not have an air traffic control tower presence.
Within these non-towered aerodromes, and in the vicinity of them,
pilots are responsible for making themselves aware of nearby
aircraft and maintaining separation. This self-separation can be
complicated by the variation in the aircraft and operations using
non-towered aerodromes, which can range from small aircraft private
flights up to high capacity regular public transport jet
aircraft.
This report will outline safety occurrence data reported to the
ATSB between 2003 and 2008 at, or in the vicinity of, non-towered
aerodromes in Australia that were related to airspace use,
separation, and procedural compliance. It will also document
changes in the number of aircraft movements and changes in the
traffic mix into 19 non-towered aerodromes since 2003.
A number of issues persist in occurrences at non-towered
aerodromes that pilots can easily address. The report analyses
these and provides simple methods for pilots to keep safe while
flying in the vicinity of non-towered aerodromes.
Expected release: July-Sept 2010.
World-wide review of data calculation and entry errors
leading to reduced performance takeoff accidents and incidents in
high capacity jet aircraft
On 20 March 2009, a foreign-registered Airbus A340 aircraft
sustained a tail strike and overran the runway during a takeoff
from Melbourne Airport. The occurrence investigation (AO-2009-012) is
on-going, but has already established that an incorrect and
undetected aircraft computer data entry by the pilots, leading to
reduced aircraft performance, was the immediate contributing
factors to this accident. Was this simple and minor error with a
potentially devastating outcome a one-off event, or are these
errors occurring without detection in other operations?
If the latter, how can they be avoided before disaster.
This research is will involve the documentation and analysis of a
small number of accidents, both from Australia and world-wide,
involving high capacity jet aircraft which have been a result of
crew calculating or entering wrong data into flight computers,
leading to reduced aircraft performance during takeoff. Analysis of
these occurrences will determine common contributing pilot actions,
local conditions, and failed or missing risk controls.
The common contributing factors will be valuable information to
assist airlines in developing procedures and training to minimise
the risk of this type of error occurring and/or leading to an
accident.
Expected release: July-Sept 2010.
Loading relating safety occurrences in high capacity
aircraft
The ATSB receives over 2,000 occurrence reports from high
capacity operations each year. Most of these are not individually
investigated by the ATSB, but collectively, these occurrence
reports provide a rich source of information. The ATSB is planning
on sifting through this data, organised around the type of
occurrence, to produce a series of short research reports to assist
airlines in understanding where safety issues lie at an industry
level.
Following on from the first report detailing ground operation
occurrences, this report explores loading occurrences.
Specifically, it will detail occurrences involving centre of
gravity issues, carriage of dangerous goods, and other loading
issues such as incorrect load sheets, loads and stowage.
Expected release: July-Sept 2010.
Australian Rail Safety Occurrence Data: 2001 to June
2010
Rail safety occurrence data is collected from the industry by
state and territory-based regulators. This data is provided to the
ATSB biannually to be compiled into a single statistical report as
the National Rail Occurrence Database on behalf of the Rail Safety
Regulators Panel. The report is designed to assist rail safety
professionals and researchers in understanding and mitigating risk.
In addition, it can be used for international comparative research,
while informing the public about emerging issues in rail
safety.
The data is presented as counts of occurrences, and normalised
through train kilometres travelled or kilometres of track, to
assist in comparisons between jurisdictions. Data presented
includes: fatalities; serious injuries; derailments; collisions;
level crossing occurrences; signals passed at danger; loading
irregularities; and track and civil infrastructure
irregularities.
Expected release: Oct-Dec 2010.
Identifying risks in transport: Safety issues and safety
actions from ATSB investigations from July 2009 to June
2010
Each year, the ATSB conducts about 100 investigations into
transport safety matters in aviation, rail and marine. Most of
these reports document safety issues (factors that have a potential
to adversely affect the safety of future operations) identified
during the investigation, along with the assigned risk level for
each safety issue. The ATSB also individually documents safety
actions completed by industry or the regulator in response to the
identified safety issues. When no or inadequate safety action
occurs, the ATSB may also release a safety recommendation, which is
required to be responded to by 90 days.
This report will document the ATSB identified safety issues and
related safety actions and recommendations for the 2009-2010
financial year. It will explore the risk levels assigned and
provide an understanding of where the greatest risks to each
transport mode appears to lie. The results will be useful for
government decision makers, regulators and the aviation, rail and
marine industries to understand if and where attention to risk
needs to be applied.
Expected release: Oct-Dec 2010.
Avoidable Accidents: Single Engine aircraft partial
enginefailure accidents
In 2006, a Lancair 360 sustained a loss of engine power soon
after lift-off followed by intermittent engine operation. The
relatively experienced pilot responded by initiating a steep right
turn followed by another steep right turn, suggesting a pilot
decision to conduct a tight circuit, before the aircraft stalled
and heavily impacted a taxiway. The pilot was fatally injured. In
addition to this accident, since 2001 there have been a number of
single-engine aircraft accidents resulting from engine power loss
during or after takeoff preceding loss of control. Partial power
loss,
sometimes intermittent, featured in most of these.
This short education style booklet will be written for general
aviation pilots, containing a number of accident case studies and
lessons learned from ATSB investigations. It will simplify this
complex issue to assist the pilots to manage the risk of operating
aircraft that do not have assured takeoff performance when an
engine loses power. Of particular focus, it will explain how pilots
have managed and should manage a partial engine power loss during
or soon after takeoff in single engine aircraft.
Expected release: Oct-Dec 2010.
Aviation Occurrence Statistics: 2001 to December
2010
The ATSB now receives over 7,000 occurrence reports from all
areas of the aviation industry every year. This annual statistical
publication documents these incidents and accidents, and represents
the official source of Australian aviation safety occurrence data.
It will present the data as meaningful information through the use
of charts and directed commentary, and arranges data by operation
type, year, aircraft types, and occurrence types. It will also
document ATSB investigations initiated in the previous year.
Expected release: Jan-March 2011.
HFACS: Relationship between aircrew unsafe acts,
preconditions and organisational factors in Australian aviation
accidents
The Human Factors Analysis and Classification System (HFACS) is
a taxonomy that describes the human factors that contribute to an
accident or incident. While the model has been widely employed to
describe the contributing factors to safety occurrences,
particularly in the United States, little has been published on the
relationships or pathways between the hierarchical levels in the
HFACS taxonomy.
The objectives of this study is to identify relationships
between the levels of the HFACS taxonomy using Australian accident
data. The outcome of these results will be useful for investigators
and researchers to understand which sorts of factors contributing
to accidents are commonly related to other factors.
Expected release: Jan-June 2011.
Australian Rail Safety Occurrence Data:2001 to December
2010
Biannual rail statistics report, as described above.
Expected release: April-June 2011.
Amateur-built and experimental aircraft Part 2: Accident
analysis
Non-factory amateur-built and experimental (ABE) aircraft are a
popular alternative to general aviation aircraft. Despite this
popularity, there has been very little information about the
relative level of safety of these aircraft when compared with
similar factory-built general aviation aircraft.
This report will explore the accident data of VH-registered ABE
and similar factory built aircraft over a 20 year period. It will
investigate whether the same types of accidents are occurring and
explore reasons for any differences found. In particular, it will
investigate whether differences in ABE aircraft, such as
user-modifications and limitations, are associated with accident
rates and types.
The results will be useful for guiding future policy and
procedural directions within the Civil Aviation Safety Authority
regarding the operation of ABE aircraft. It will also be useful for
current and prospective owners of ABE aircraft to assess the risks
associated with operating these types of aircraft.
Expected release: Jan-June 2011.
Regional airline safety study Part 1: Current status of
the regional industry and changes since 1997
In May 1999, the Bureau of Air Safety Investigation released a
research report titled Regional Airline Safety Study Project
Report, which sought to identify safety deficiencies affecting
regional airline operations in Australia and identify measures to
reduce the impact of such deficiencies. Since this time, the
regional airline industry in Australia has experienced a number of
changes, both regulatory and operational.
The purpose of this report is to provide a comprehensive review
of the regional airline industry and identify current and emerging
issues.
This report will be able to be used by policy makers and those
in the regional airline industry to help identify what changes have
occurred in the regional airline environment and how they may
continue to evolve.
Expected release: Jan-June 2011.
Avoidable Accidents: Experience is no
defence
Over the past few years, a number of high-profile pilots in the
Australian aviation community have been involved in fatal
accidents. These pilots were considered by many to be at the
pinnacle of flying experience, skill and ability. Yet, their own
actions ultimately contributed to their fatal outcomes.
This educational booklet will document a number of fatal
accidents involving very experienced pilots and explore some of the
reasons contributing to their fatal accidents. Intended for pilots
in general aviation, sports aviation and recreational aviation, it
will outline lessons learned and hopefully help instil a culture of
healthy respect for the risks posed by aviation no matter what
level of skill and experience the pilot has.
Expected release: Jan-June 2011.
Technical failures related to Australian aviation
accidents
While the reliability of aircraft has improved significantly as
aviation developed into an established transport industry,
technical failures still continue to feature and have the potential
to increase the risk of accidents. This report will document the
technical failures associated with aircraft accidents and
incidents, including the types of failures and the contributing
factors for these failures (design, manufacture, maintenance,
operation); and investigate why some failures result in more
adverse outcomes than others.
An understanding of which technical failures are the most common
and which failures are more likely to lead to accidents will help
airlines and other operators focus their effort in terms of pilot
training and procedures to prepare and manage technical failures
when they occur.
Expected release: July-Dec 2011.
Runway Incursions
Runways are critical locations for aviation safety as they
involve high-speed and high-energy aircraft movements. As aircraft
are sharing the same physical space for takeoffs and landings,
aircraft separation relies on managing the timing of runway use.
While collisions between aircraft on runways are rare, the
potential for two aircraft or an aircraft and a vehicle to be on
the runway at the same time are numerous and the ATSB receives many
reports of every of such runway occur, it can be of high
consequence, such as the incidents year incursions. If a collision
does worlds worst aircraft accident at Tenerife in 1977 resulting
in 583 fatalities.
This research report will investigate runway incursions at
airports operated to by high capacity aircraft. It will determine
which airports are the most affected by runway incursions, what
types of aircraft and vehicles are causing the incursions, and the
trends associated with runway incursions in general. If possible,
it will review and document the factors contributing to runway
incursions. This investigation should assist air traffic
controllers' and pilots' awareness of runway incursions.
Expected release: July-Dec 2011.
Violation of controlled airspace
occurrences
Many general aviation aircraft fly in uncontrolled airspace
which, among other reasons, helps assure sufficient separation
between them and often considerably faster and larger aircraft
operating in controlled airspace. This separation assurance breaks
down when aircraft stray into controlled airspace, especially when
this is not realised by the pilot and/or air traffic control cannot
contact the pilot involved. At worst, although not seen in
Australia, this could result in a mid-air collision.
This research investigation aims to determine which airspace
areas and locations have the highest incidents of violations of
controlled airspace (VCAs), and to explore the trends associated
with VCAs in general. If possible, it will also review the factors
that are contributing to VCAs.
This information should assist airlines to increase awareness
among pilots about where they are more likely to encounter an
uncontrolled aircraft in controlled airspace, and provide flying
training schools and aero clubs of an awareness of areas to
increase positional situational awareness.
Expected release: July-Dec 2011.
Australian Rail Safety Occurrence Data:2001 to June
2011
Biannual rail statistics report, as described above.
Expected release: July-Dec 2011.
Accidents from mishandling errors
Accidents can have a range of contributing factors, but one of
the most basic can involve the pilot's ability of appropriately
handle the aircraft, often in non-normal and difficult conditions.
This research will investigate accidents where inappropriate
aircraft handling contributing to the outcome and document the
prevalence of the various handling errors.
This report will be useful to the aviation training industry and
the regulator. The results will be able to feed into the
development of the required flying training syllabi and provide
advice to training organisations as to what skills need to be
emphasised during flying training.
Expected release: July-Dec 2011.
Occurrences related to failure to comply with air
traffic control altitude clearances
Non-compliance with air traffic control cleared altitude levels
by pilots are a threat to other airspace users. This report will
explore why breaches are occurring, including when they are
intentional or accidental, where they are occurring, which types of
operation are responsible, and the consequences of these incidents.
This will be achieved through exploring reports to the ATSB of
non-compliance of altitude clearances and following-up newly
reported incidents through short telephone interviews to help
understand the contributing factors.
This report should be useful to both air traffic control
services and pilots to help understand why non-compliances are
occurring to help avoid them and/or any consequences associated
with them into the future.
Expected release: July-Dec 2011.
Recreational aviation incidents and
accidents
Recreational aviation, in particular non-VH-registered powered
ultralight and light sports aeroplanes, have become an increasingly
significant proportional of non-commercial aviation in Australia.
However, little is known about the relative safety of this part of
the aviation industry.
This report will document the types of safety incidents and
accidents reported to the ATSB from aircraft registered through
Recreation Aviation Australia. The results will be valuable for
regulators and decision makers in government and within the
recreational industry to gauge the level of safety and understand\
where the largest risks to safety, if any, within this sector
lies.
Expected release: July-Dec 2011.
Wildlife strikes: Bird and animal strike statistics:
2002 to 2011
A significant proportion of all occurrences reported to the ATSB
involve aircraft striking wildlife, especially birds. While most
birdstrikes do no result in damage or affect the safety of the
flight, a small proportion do, and as seen in overseas accidents,
there is always a possibility of ingesting birds into all engines
or strikes resulting in significant damage to an aerodynamic
structure. As such, aerodromes, airlines and others in the aviation
industry must remain vigilant of birdstrike risks and mitigate as
much as practicable through aerodrome wildlife control,
observations, reporting and avoidance.
This report will provide aviation birdstrike and animal strike
occurrence data for the period 2002 to 2011, updating the previous
report released in 2010. It will document the number and rate of
birdstrikes and animal strikes by operation type, locations,
aircraft damage and injury, species and bird/animal size involved,
and number of birds struck.
Expected release: Jan-June 2012.
Aviation Occurrence Statistics: 2002 to December
2011
Annual aviation occurrence statistics report, as described
above.
Expected release: Jan-June 2012.
Australian Rail Safety Occurrence Data:2001 to December
2011
Biannual rail statistics report, as described above.
Expected release: Jan-June 2012.
Avoidable accidents: Fuel planning
accidents
Every year, the ATSB receives reports of forced landings and
other accidents related to aircraft being short of fuel. Sometimes,
these occurrences can be fatal. Although this is a well known issue
in aviation, these accidents continue to occur.
The aim of this educational report is to document a number of
related accidents that were the result of inadequate fuel planning.
Drawing together these case studies, the booklet will also look the
lessons learned from these accidents to raise awareness among
general aviation pilots of the possible traps and other
circumstances that can ultimately lead to inadequate fuel on-board
to help reduce these accidents.
Expected release: Jan-June 2012.
Regional airline safety study Part 2: Accident and
incident analysis
A continuation of the regional airlines project, this report
will explore safety occurrences reported to the ATSB over the past
decade in relation to regional airlines and investigate whether the
nature of these have changed and where the major risks to regional
airlines safety now lies.
Expected release: Jan-June 2012.