Ship operators need to ensure that they have an appropriate process in place to properly manage the level of crew fatigue according to the Australian Transport Safety Bureau (ATSB). The advice is a result of the ATSB's investigation into the 3 April 2010 grounding of Chinese bulk carrier Shen Neng 1 on Douglas Shoal, off the coast of Queensland near Gladstone. In its final investigation report, released today, the ATSB found that the chief mate was affected by fatigue and this resulted in a decreased level of performance while he was monitoring Shen Neng 1's position. The report found that…
Aircraft take-off performance errors resulting from simple human data calculation or entry occur too frequently but can be avoided or detected, according to an ATSB research report, released today. The report examines Australian and international occurrences between 1 January 1989 and 30 June 2009 that involved the calculation and entry of erroneous take-off data. It reveals that take-off errors happen for many different reasons such as the wrong figure being used as well as data being entered incorrectly, not being updated, or being excluded. Importantly, the report identifies that while no…
The importance of maintaining situational awareness and the risks of pilot distraction are two of the major safety lessons featured in the latest edition of the ATSB's investigation bulletin, released today. Situational awareness was a factor in air proximity events, breakdowns of separation, ground handling and wirestrikes. An example of a situational awareness issue occurred when a Pilatus PC-12/45 and Aeronautica MacchiAL60 passed within close proximity to each other while flying. This incident highlighted the need for aircrew to conduct diligent radio broadcasts and continual visual…
The Australian Transport Safety Bureau (ATSB) is urging shipping operators to regularly check and replace their container lashing equipment as a result of an incident involving the Hong Kong registered container ship Pacific Adventurer. On 11 March 2009, Pacific Adventurer lost 31 containers overboard during severe weather and large swells off Cape Moreton, Queensland. As the unsecured containers went overboard, they holed two of the ship's fuel oil bunker tanks. This caused the ship to leak 270 tonnes of bunker oil into the sea which affected 70kms of Queensland's coastline. The ATSB…
Operators of Robinson R44 helicopters are being advised to inspect the security of their helicopters' hydraulic-boost servos following a fatal accident at Cessnock Aerodrome, NSW. On 4 February 2011, a Robinson R44 Astro helicopter crashed after part of the aircraft's flight controls separated from the hydraulic-boost system during circuit operations. The pilot survived, but the flight instructor and a passenger died in the accident. The Australian Transport Safety Bureau's (ATSB's) preliminary factual report, released today, reveals that a bolt securing part of the flight control system had…
The ATSB will conduct an onsite media briefing on its investigation into the 30 March 2011 fatal aircraft accident at Moree, NSW. The Investigator-in-Charge Mr David Grambauer will discuss factual information known to the ATSB at this time and will outline the investigation process. The ATSB has deployed four investigators, three from Canberra and one from Brisbane, who will arrive at Moree later today. Over the next few days they will examine the wreckage site, interview witnesses and collect maintenance records. Where: Accident site (Blueberry Road, Moree) When: 11.00am (AEDT), 1 April 2011
On Thursday 14 April 2011, the Australian Transport Safety Bureau (ATSB) will hold a media briefing to accompany the release of its final investigation report into the 3 April 2010 grounding of Chinese bulk carrier Shen Neng 1 on Douglas Shoal, off the coast of Queensland near Gladstone. ATSB Chief Commissioner Mr Martin Dolan will present the facts of the investigation and highlight the key safety actions that have occurred to prevent a recurrence. Where: 62 Northbourne Avenue, Canberra City, ACT(ATSB Central Office) Time: 10.30am (AEDT), Thursday 14 April 2011 Copies of the investigation…
The ATSB is reminding aerial work pilots to manage their fatigue levels as they take on higher workloads during this time of the year. The ATSB's advice follows an incident where a pilot fell asleep while undertaking locust spotting activities and had to be awoken by an observer on the plane. ATSB Chief Commissioner, Mr Martin Dolan, said aerial work pilots are especially prone to becoming fatigued during this time of the year. "As pilots increase their flying hours doing high intensity agricultural activity, such as spotting and spraying, they are at far greater risk of becoming fatigued,"…
In a preliminary investigation report released today, the ATSB outlines safety actions that have already been taken in response to an uncontained engine failure on board a Qantas A380 aircraft over Batam Island, Indonesia on 4 November 2010. "The investigation highlights Australian and international cooperation in the interests of aviation safety," said the ATSB's Chief Commissioner, Martin Dolan. "The ATSB is the lead investigator, but many others are involved, and their cooperation has been essential". "We're still in the early stages of investigation," Mr Dolan added, "but significant…
The ATSB has issued a safety recommendation about potential engine problems in some Airbus A380 aircraft. The safety recommendation identifies a potential manufacturing defect with an oil tube connection to the high-pressure (HP)/intermediate-pressure (IP) bearing structure of the Trent 900 engine installed in some A380 aircraft. The problem relates to the potential for misaligned oil pipe counter-boring, which could lead to fatigue cracking, oil leakage and potential engine failure from an oil fire within the HP/IP bearing buffer space. In response to the recommendation Rolls Royce, affected…