Review by the Chief Commissioner
The Australian Transport Safety Bureau (ATSB) became a separate statutory agency on 1 July 2009. This was the final step in the transition to independence from being an operational division of the Department of Infrastructure, Transport, Regional Development and Local Government. This Annual Report covers the first year of operations under those new arrangements.
Operational start‑up for the new organisation was smooth and well‑controlled, thanks in large part to the hard work of our corporate services staff and our colleagues in the Infrastructure Department. At the same time, the ATSB continued to deliver its core business of conducting transport safety investigations, some of which were complex and the subject of significant industry and public interest both in Australia and internationally. A number of those investigations led directly to significant initiatives to improve transport safety.
Legally, the ATSB consists of three Commissioners: Mr Noel Hart, Ms Carolyn Walsh and me. The three of us are generally referred to as 'the Commission'. As the Chief Commissioner, I am also Chief Executive Officer of the ATSB, with responsibility for the employment of staff and the management of financial and other resources.
One of the Commission's most important responsibilities is to ensure that a transport safety investigation is complete and that a final report can be published; this includes determining what important safety messages arise from an investigation and the best means to communicate those messages.
The Transport Safety Investigation Act 2003 reinforces this responsibility: it requires the Chief Commissioner to describe in the ATSB's annual report those investigations that have raised significant issues in transport safety. This review meets that requirement. Some of the investigations described below are not yet finished. It is the ATSB's policy, however, to bring critical safety issues to the immediate attention of those best placed to take prompt action.
Rail safety investigation
The rail investigation team completed 11 transport safety investigations in the past year. Two of those investigations were conducted on behalf of the Queensland Department of Transport and Main Roads, in accordance with provisions of Queensland's Transport Infrastructure Act 1994, with a senior ATSB rail safety investigator as the independent chair of the investigation team. These high‑profile investigations involving passenger trains at level crossings were conducted in a timely manner and resulted in wide‑ranging safety action by the Queensland Government.
They and other investigations highlight the continuing issues of road design, marking and road use that are the most significant influences on safety at level crossings, particularly where heavy road transport vehicles are involved.
In the course of a number of other investigations, the ATSB continues to observe a concerning pattern of safe‑working irregularities, including some resulting in fatalities, that are principally attributable to communications issues. We draw the attention of rail operators to the need for improved procedures and training in effective radio communication between train controllers and train crew and track workers.
Marine safety investigation
The marine investigation team completed 11 safety investigations, including one in assistance to the New Zealand Transport Accident Investigation Commission (TAIC). While all investigations are conducted by the ATSB with the aim of identifying and promulgating useful safety messages, there were two in particular that, from my perspective, raise significant issues in transport safety.
The first is the collision of the yacht Ella's Pink Lady and the bulk carrier Silver Yang. The investigation found that when the two vessels collided, neither the yacht's skipper nor the ship's watch keepers were keeping a proper lookout, nor were they appropriately using navigational aids to manage the risk of collision. The investigation also found that following the collision, the ship's watch keeper did not adequately offer to assist the yacht's skipper.
Failure to stop and render assistance is a problem that has also been highlighted by previous ATSB investigations and is a continuing problem around the world.
The investigation serves as a timely reminder that, under United Nations conventions, ship operators have an obligation to offer assistance immediately to other vessels following a collision.
The second significant investigation involved the container ship APL Sydney, which ruptured the submarine ethane gas pipeline in Port Phillip after dragging its anchor across the pipeline in strong gale force winds.
The ship's anchor had been let go too close to the pipeline in poor weather conditions and insufficient anchor cable was deployed. Inadequate action was taken on board the ship and at harbour control to prevent the anchor from snagging the pipeline. After snagging the pipeline, the anchor windlass failed. Instead of releasing the fouled anchor, an attempt was made to clear it and this led to the pipeline rupture.
After the rupture, APL Sydney was manoeuvred clear of the escaping gas and the pipeline. There were no injuries and the pipeline was isolated. The anchor cable was cut and left in the anchorage with the anchor. Repairs to the pipeline took several months.
The ATSB investigation identified 10 significant safety issues in relation to the port's risk management, with respect to the pipeline and anchorage boundaries and its shipping control procedures, the ship's safety management system, the pilotage company's safety management system, and the windlass failure. Safety action to address all of the safety issues identified was proactively taken by the relevant parties.
Of particular significance, given other investigations and occurrences internationally, are the ongoing issues of effective bridge resource management when a pilot is on board a vessel. The ATSB draws attention to the need for training of pilots and deck officers to give emphasis to issues of role clarity between pilots and officers, cross‑cultural issues and the need for clear communication protocols.
Aviation safety investigation
The aviation investigation teams completed 68 aviation accident and incident investigations in the past year, several of which attracted substantial national and international interest. Many of those investigations, both completed and ongoing, have helped to identify important safety issues.
The first is an occurrence involving an A320 aircraft that performed an incorrect go‑around in fog at Melbourne Airport. In the process, the crew was unaware of the aircraft's current flight mode. The aircraft descended to within 38 ft of the ground before climbing.
The investigation highlighted the risks of changing standard operating procedures, particularly without formal risk management processes. Even more significantly, it provided more evidence that issues remain about the adequacy of some elements of oversight and delivery of pilot training. These issues are also coming into prominence in a number of other aviation investigations.
The aircraft operator has commenced a review of its flight training requirements, and the Civil Aviation Safety Authority (CASA) is reviewing the regulations relating to the provision of flying training by third party training providers. The ATSB nevertheless draws attention to the safety significance of effective training oversight, whether delivered by third parties or in‑house. The ATSB will be directing further investigative efforts to this area of potential safety risk.
The second is an occurrence involving an Embraer 120 aircraft at Jundee Airstrip, Western Australia. On final approach to the airstrip, the aircraft unexpectedly drifted left of the runway centreline and the crew decided to initiate a go‑around, whereupon the aircraft violently rolled and yawed left. The crew had difficulty controlling the aircraft and narrowly avoided colliding with the ground.
The ATSB investigation established that the left engine had sustained a total power loss following fuel starvation. That had occurred because the left fuel tank was empty.
The ATSB identified multiple safety factors associated with the fuel quantity indicating system, the ability of the crew to recognise the left engine power loss, and their performance during the go‑around.
After the incident, the operator introduced revised procedures for measuring fuel quantity, and CASA initiated a project to amend the guidance to provide better clarity and emphasis. In March 2009, an EMB‑120 flight simulator came into operation in Melbourne, Victoria. CASA has advised that a Notice of Proposed Rule Making relating to simulator training requirements will be released by the end of July 2010 with a response period of six weeks. Final rule making is expected to be accomplished toward the end of the calendar year.
The occurrence does, however, also draw attention to several other significant safety issues that are also appearing in other investigations. These include a pattern of problems with stabilised approaches to landing, a number of instances of potential and actual accidents arising from inadequate fuel management, and some early indications of systemic problems with the handling of asymmetric engine conditions.
In each of these cases, the ATSB will be doing further work to establish the scope and scale of the problem. In the meantime, we encourage operators to make their own assessments in these areas to satisfy themselves that the risk is as low as reasonably practicable.
Finally, the ATSB draws attention to an aspect of its trend analysis of safety in general aviation. The fatality rate has not significantly varied over the last ten years, nor has the relative proportion of the major contributors to those fatalities: fuel management, controlled flight into terrain, wire strikes and visual flight in instrument conditions. Detailed investigation is adding little safety value. It is clear that a shift of emphasis to greater safety education is necessary.