All occurrence investigations progress through a series of phases in accordance with the ATSB’s investigation methodology to ensure a rigorous and comprehensive investigation report with evidence-based findings that lead to improvements in transport safety.  Evidence collection   During the evidence collection phase, investigators build a detailed picture of the occurrence or other transport safety matter being investigated. Evidence gathered may include:  site observations and mapping, including recording wreckage distribution…

Safety concern The ATSB has investigated several accidents that have occurred when maintenance work was being carried out on or near railway tracks. Conducting work on or near a railway track can be dangerous if safeworking rules and procedures have not been correctly implemented to protect the worksite. Trains cannot stop quickly and any breakdown in the communication or management of a worksite can leave workers extremely vulnerable to dangerous situations.

Safety concern An increasing trend has been identified where pilots do not effectively manage their aircraft’s flightpath when unexpected events arise during the approach to land. When compared to other phases of flight, the approach and landing has a substantially increased workload and is traditionally the phase of flight associated with the highest accident rate. Flight crews must continuously monitor aircraft and approach parameters, and the external environment, to ensure they maintain a stable approach profile and make appropriate decisions for a safe landing. The selection of…

Safety concern There have been numerous accidents worldwide that were the result of simple human errors in data calculation or entry. Data errors—such as the wrong figure being used as well as data being entered incorrectly, not being updated, or being excluded—happen for many different reasons. The consequences of these sort of errors can range from aborted take-offs through to collisions with the ground. Errors can occur irrespective of pilot experience, operator, aircraft type, location and take-off performance calculation method.

Safety concern It is difficult for pilots to identify other aircraft through visual observation alone. The ATSB often receives reports from pilots that another aircraft is flying too close to them in uncontrolled airspace. Not surprisingly, three quarters of these reports involve pilots flying within 10 nautical miles (18.5 kilometres) of a non-controlled aerodrome. In nearly three quarters of all near-collisions reported to the ATSB, at least one pilot had no prior warning of the other aircraft in their vicinity. Insufficient communication between pilots operating in the same area is the…

Safety concern The ATSB has investigated a number of incidents and accidents where fatigue was identified as having a causal effect. Human fatigue is a physical and psychological condition primarily caused by prolonged wakefulness and/or insufficient or disturbed sleep. Everyone has experienced fatigue at some point, but in the transport industry, where there’s often high pressure to deliver, fatigue can have very real, very dangerous implications. Fatigue can have a range of adverse influences on human performance, such as slowed reaction time, decreased work efficiency, reduced…

Easter message from Greg Hood, Chief Commissioner of the Australian Transport Safety Bureau Watch the video message  

As the accountable authority for the Australian Transport Safety Bureau (ATSB), I am pleased to present the ATSB’s 2017–18 Corporate Plan, which covers the period 2017–18 to 2020–21.This Corporate Plan sets out the ATSB’s purpose – to improve transport safety – and its strategies for achieving that purpose. The Plan also sets out the ATSB’s key deliverables and associated performance criteria. It has been prepared consistent with paragraph 35(1)(b) of the Public Governance, Performance and Accountability Act 2013 and the relevant provisions of the Transport Safety Investigation Act 2003 (the…

As the accountable authority for the Australian Transport Safety Bureau (ATSB), I am pleased to present the ATSB’s 2016–17 Corporate Plan, which covers the period 2016–17 to 2019–20. This Corporate Plan sets out the ATSB’s purpose, its strategies for achieving that purpose and how the effect of the strategies and the attainment of the ATSB’s purpose will be measured. It has been prepared consistent with paragraph 35(1)(b) of the Public Governance, Performance and Accountability Act 2013. The Plan takes account of the relevant provisions of the Transport Safety Investigation Act 2003 (the TSI…

Fatal accident prompts safety recommendations for skydiving operations A multi-fatal accident involving a Cessna U206G aircraft has resulted in the ATSB issuing recommendations to improve the safety of skydiving operations in Australia. The 22 March 2014 accident occurred when the aircraft was conducting tandem parachuting operations at Caboolture in Queensland. On board were the pilot, two parachuting instructors and two tandem parachutists. Shortly after take-off, the aircraft climbed to about 200 feet before aerodynamically stalling and colliding with the ground. Tragically, all five died…