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.
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Research Investigations & Data Analysis Program January - June 2013
Avoidable Accidents 6: Experience won’t always save you: Pilot experience is not always a protection against an accident
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: February 2013.
High capacity air transport review: stall warnings
Developing from the ATSB's trend monitoring capability to look for emerging safety issues in reported occurrence data, the intent of this series of data-driven short publications is to review occurrences reported by high capacity air transport operators in different areas to see what characterises them, and what (if any) trends are evident in the data. In this publication, stall warnings, mostly characterised by stick-shaker events, will be documented by how many there are, what the typical sorts of occurrences are, what typical defences for an actual stall are left, and what are some high risk situations and when have they occurred. The aim of the reports is to clearly communicate useful information garnered from the ATSB occurrence dataset that operators and regulators can use to learn from the experiences of others.
Expected release: February 2013.
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: March 2013.
A review of the effectiveness of emergency locator transmitters (ELTs) in aviation accidents
Emergency location transmitters are radio beacons carried on most aircraft so that in the event of an accident in a remote location, the aircraft wreckage and its occupants can be located quickly by search and rescue (SAR) operations. Airframe mounted emergency locator transmitters (ELTs) are designed to automatically activate following an impact typical of a collision. However, the effectiveness of airframe ELTs in aviation accidents has been questioned for some time by accident investigation agencies and by the aviation community. Beyond individual examples of ELTs not activating following an accident, however, there has been little research done to date to review how reliably ELTs operate as designed after an aircraft accident. In this report, the ATSB will identify safety concerns regarding the operation of ELTs and present data on the effectiveness of ELTs in those accidents in which their deployment could have been beneficial in assisting SAR operations and/or post-crash survivability.
Expected release: March 2013.
Australian shipping safety statistics: 2005-2012
This report will document marine safety reportable matters from 2005 to 2012 to document the number and types of marine safety occurrences involving Australian registered ships anywhere in the world, foreign flag ships within Australian waters. As the second edition, this report will add a further two years of data from the first edition.
Expected release: April 2013.
Aviation occurrence statistics: 2003-2012
Based on the thousands of reported occurrences the ATSB receives each year, this report aims to give information back to the aviation industry on what accidents and incidents have happened, how often they are happening, and what we can learn from them. This annual report documents the trends over the past decade, with an emphasis on occurrences from 2012. It will document aviation activity, and the number and rate of occurrences by operation type, aircraft type, and the type of occurrence.
Expected release: May 2013.
Identifying risks in transport: Safety issues from ATSB investigations from July 2009 to June 2012
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 2011-2012 financial year and trends across three financial years. 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: March 2012.
Loss of Separation occurrences
Loss of separation (LOS) occurrences involve aircraft getting closer to each other than the prescribed separation standard in airspace controlled by air traffic control. These standards are set to ensure that mid-air collisions do not happen, and when they are broken, there are fewer defences left to guard against a mid-air collision.
Since 2010, the total number of reported LOS occurrences has been steadily increasing, although the number per quarter is still lower than in 2006 and 2007.
This research investigation is being conducted under Part 21 of the Transport Safety Investigation Act. The investigation will examine 4.5 years of occurrence data, 18 months of findings from ATSB investigations of LOS occurrences, and issues raised in REPCON confidential reporting relevant to air traffic control. The investigation will include both defence and civilian air traffic control, and will document common factors associated with LOS occurrences.
The report should be useful for both civilian and defence air traffic control services to help understand separation breakdown issues in Australia.
Expected release: April 2013.
Runway excursions: overruns and veer-offs in general aviation and low capacity operations: 2000-2011
There are about 50 to 60 runway excursions each year involving general aviation and low capacity aircraft. Excursions can happen during a takeoff or landing, and can involve an overrun of the runway or a veer-off from the side of a runway. This report will document the runway excursion accidents from 2000 to 2011, and look for evidence for runway, pilot, weather, and other factors that contribute to these accidents.
This report will be useful for flying instructors and pilots to help determine which factors are more likely to lead to runway excursions so that such factors can be trained and planned for.
Expected release: May 2013.
Exploring the link between pilot experience and performance in non-normal scenarios
The subject of pilot experience has recently come to public attention in Australia through the Senate Inquiry into pilot training which looked at raising the minimum pilot hours required before first officers could work for an airline. The topic has also come to prominence internationally with high profile accidents such as the Colgan Air Dash-8 accident at Buffalo, U.S. Further, the introduction of the Multi-crew Pilot Licence (MPL) by ICAO allows pilots with less than 250 hours to enter an airline as a direct entry first officer. However, there is no research in the current literature that has compared the performance of pilots in an airline that have entered the airline through this new training pathway rather than through the traditional flying experience path. As such, the question of whether low hour pilots have inadequate performance which is significantly different to their more experienced colleagues is a potential safety issue that could affect future transport safety. Using data collected in flying simulators by three high capacity airlines, this research investigation will examine pilot performance in off-nominal or non-normal situations in a simulator, as a function of pilot experience. Specifically, it will compare performance of second and first officers with less than 1,500 hours experience with those with more experience. It is also planned to examine the training pathways of second and first officers to determine if differences exist as a result of their training.
Expected release: June 2013.
Future research and analysis topics
Avoidable Accidents: Flying visually at night
The ATSB have recently investigated a number of accidents involving VFR pilots flying at night or dusk. Some of these accidents have involved Night-VFR rated pilots, others have involved VFR pilots caught out after last light. Others have involved similar issues but involved IFR pilots flying at night visually. Such accidents have happened for several reasons, but have been a common type of accident in general aviation over the decades and continue to occur. This educational booklet with document several accidents involving flying visually at night, and will provide the general aviation community with advice about how to appropriately deal with these situations.
Avoidable Accidents: Autorotation accidents during helicopter training
A number of recent helicopter accidents have been a result of pilots mis-handling an autorotation during training. This educational booklet will document several accidents, and explore some of the reasons contributing to these accidents. Intended for pilots in general aviation and the helicopter training industry in particular, it will provide helicopter pilots with positive advice about how to prepare and handle these situations appropriately.
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.
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.
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