The ATSB has released a 500-page final report into Australia's worst civil aviation accident since 1968. The report spells out contributing safety factors involving the pilots, the operator and the regulator as well as other safety factors, and has made further recommendations to improve future safety. An Australian Transport Safety Bureau team of a dozen investigators has taken nearly two years of painstaking investigation to complete the final report since the tragic accident on…

The ATSB has found it is likely that some passive level crossings in the Northern Territory, Queensland, Western Australia and South Australia that are controlled by 'Stop' signs and are used by high combined gross mass road vehicles may have deficient sighting distances. The Australian Transport Safety Bureau has released a supplementary report on this potential problem as part of its continuing investigation into the 12 December 2006 collision involving The Ghan on the Fountain Head Road level crossing at Ban Ban Springs, NT. The Fountain Head Road…

The ATSB is reviewing scope for possible action against Transair but re-emphasises that this is unrelated to the Transair accident on 7 May 2005 when all 15 on board lost their lives. The Deputy Prime Minister as Minister for Transport and Regional Services has today been informed that earlier advice from the ATSB suggesting that it was unable to pursue any prosecution with respect to some more serious incidents that Transair failed to report before the accident was incorrect. The ATSB has apologised to the Minister. The ATSB wishes to highlight that it…

According to the ATSB investigation, the 'knockdown' of the sail training vessel Windeward Bound, in Bass Strait, was the result of inadequate preparations by the ships crew and the use of excessive rudder movements at the time that a forecast severe cold front passed over the vessel. On 3 June 2004, Windeward Bound was off the Victorian coast, heading northeast at about six knots. The wind was from the northwest and the vessel was heeled between 10 and 15 degrees to starboard. The upper and lower topsails, the main and fore staysails were set. While a cold front was expected, the ship's…

The ATSB has found that the crew on board the Isle of Man registered oil tanker British Mallard did not prevent the ship's elevator car from moving while they were working in the elevator shaft and, as a result, it moved unexpectedly, trapping and killing the ship's electrical technician. The Australian Transport Safety Bureau investigation found that the ship's crew were either not aware of, or did not consider, all of the hazards associated with working in the elevator shaft. The investigation also found that the elevator instruction manuals did not provide detailed and unambiguous safety…

The ATSB has found that the use of starboard instead of port helm led to the grounding of the Singapore registered woodchip carrier Crimson Mars in the River Tamar on 1 May 2006. The Australian Transport Safety Bureau investigation found that an unsuitable conning position, ineffective bridge resource management and the distraction caused by the use of a mobile telephone may have contributed to the helm being applied the wrong way. It was also found that inadequate monitoring of the helm orders and their execution led to the error not being detected in time to prevent the grounding. At 1400…

The ATSB has found that neither the harbour pilot nor the ship's crew adequately considered the ships speed or its movement in the prevailing conditions and this led to the Indian oil tanker Desh Rakshak grounding near Point Lonsdale. The Australian Transport Safety Bureau investigation found that the depth of water below the ship's keel was less than the bridge team had anticipated; and the Port Phillip Sea Pilots procedures did not give effective guidance to the pilot when deciding whether, or not, to pilot the ship from sea to the Melbourne outer anchorage in the prevailing conditions. It…

The ATSB has found that a lack of passage monitoring resulted in the Vanuatu registered offshore tug/supply ship Massive Tide grounding on Rosemary Island, off Dampier Western Australia, at 0445 on 29 August 2006. The Australian Transport Safety Bureau investigation found that fatigue probably impaired the performance of both the master and the officer of the watch and that the officer of the watch did not adequately monitor the ships progress during the voyage from the jack-up drill rig Ensco 106 to Dampier on the morning of 29 August. At 0100 on 29 August, Massive Tide departed the drill…

The ATSB has found that a high-pressure oxygen system fire on board the roll-on/roll-off cargo ship Searoad Mersey, on 22 September 2006, occurred when an unsuitable replacement hose fitted to the system ignited. The ship's trainee engineer was hit in the head by the gas pressure regulator and received burns to his face, head and arms. At about 1540 on 22 September 2006, the trainee engineer was preparing the fixed oxy-acetylene system for a small hot-work job when two of the oxygen system's high-pressure hoses, and the oxygen regulator, exploded in a flash fire. It is probable that, when the…

The ATSB has found that insufficient train braking and inadequate warning distance contributed to a collision between a track mounted excavator and a freight train at Inverleigh, Victoria on 25 September 2006. The Australian Transport Safety Bureau investigation established that the collision occurred because the train driver's initial brake applications approaching the work site were too little too late and that the outer flag person protecting the worksite was not positioned far enough away from the site given the anticipated train traffic, the line speed and the descending gradient. The…