The ATSB Annual Review documents ATSB's achievements and safety activities from 1 July 2004 to 30 June 2005 and outlines its business planning for 2005-2006. Executive Directors message In 2004-05 the ATSB benefited considerably from the funding boost for aviation investigations and aviation database replacement that was provided in the May 2004 Federal Budget. During the year, the Bureau recruited and commenced training 12 extra aviation safety investigators, instigated 109 aviation occurrence investigations and released 98 aviation investigation reports, up from around 60 in recent years.…

Recorded voice data, such as from cockpit voice recorders (CVRs) or air traffic control tapes, can be an important source of evidence for accident investigation, as well as for human factors research. However, most of the analysis has been based on subjective interpretation rather than the use of systematic methods, particularly when dealing with the analysis of crew interactions. Conversation analysis uses highly detailed and revealing transcriptions of recorded voice (or video) data that can allow deeper analyses of how people interact. When analysing recorded voice data, and especially for…

Boeing Commercial Aircraft Group, 747-436, G-BNLD 1. FACTUAL INFORMATION 1.1. History of the flight On the evening of March 1, 2002, Boeing 747-436 aircraft G-BNLD sustained the failure of the number-3 (right inboard) engine during a scheduled regular passenger transport flight from Sydney to Bangkok. The flight crew experienced vibrations and received an ENG 3 REVERSER engine indicating and crew alerting system (EICAS) message. The crew shut down the number-3 engine and completed checklist items before returning the aircraft to Sydney. An initial engineering examination found that a fan…

Boeing 767-238, VH-EAQ EXECUTIVE SUMMARY The left engine of a Boeing 767-238 aircraft (VH-EAQ) failed during the climb phase of a regular passenger transport flight from Melbourne to Sydney. After the failure, which was characterised by a single loud 'bang' and severe vibration, the engine was shut down and the aircraft returned to Melbourne. Engineering inspections of the JT9D-7R4 engine found that one of the fan blades had failed part-way along its length and impacted the fan case at the 11 o'clock position, causing the failure of several nose-cowl bolts and substantial damage to components…

The ATSB Annual Review 2002 documents ATSB's achievements and safety activities from 1 July 2001 to 30 June 2002 and outlines its business planning for 2002-2003 Executive Directors message The Australian Transport Safety Bureau has made significant progress since it began on 1 July 1999 as an operationally independent body within the Commonwealth Department of Transport and Regional Services (DOTARS). During 2001-02, the ATSB assisted the Minister for Transport and Regional Services to develop new legislation that would enable the Bureau to investigate rail accidents on the increasingly…

Sikorsky S76 Helicopter, VH-EXX 1. FACTUAL INFORMATION 1.1 Introduction A Sikorsky S76C helicopter (VH-EXX) sustained a failure of the number-two engine during cruise flight. The failed engine was a Turbomeca Arriel 1S1 turboshaft engine, serial number 15038 and had accumulated 7,935 hours and 6,784 cycles since new. Reports from the flight crew indicated that the engine failure was associated with a loss of gas-generator turbine speed and an escalation of turbine outlet temperatures. Fire warnings for the engine were also received, prompting the pilot commanded shutdown of the engine and…

On 30 October 2001, the University of Queensland Department of Mechanical Engineering (UQ), launched an experimental supersonic-combustion ram jet (scramjet) payload via a two-stage solid-fuel rocket that was provided by Astrotech Space Operations Inc (Astrotech). The rocket was launched from the Woomera Prohibited Area in northern South Australia, that was operated by the Department of Defence (DoD). The planned flight was to validate data obtained in the hypersonic wind tunnel at the UQ facilities. The launch occurred at 1301 Australian Central Summer Time and according to observers and…

Australia has an excellent air transport safety record. Major Australian airlines have long been regarded as being among the world's safest, and there have been no fatalities involving an Australian high capacity jet aircraft. This enviable record is due, in part, to an aviation safety culture that recognises the need for constant safety awareness. Given the commercial pressures facing international aviation, the events described in this report should be seen as a learning experience for the aviation industry, regulatory bodies, and all organisations concerned with continuing airworthiness…

This report describes the results of a national survey of transport companies in Australia. The aim was to survey companies about knowledge and awareness of fatigue, about workrest scheduling practices and about the factors which underlie the way schedules are organised. The survey was designed to provide complimentary information to that obtained in a national survey of drivers undertaken at the same time, and reported elsewhere. Telephone interviews with 200 companies carrying freight over distances greater than 300km were undertaken, covering all regulated mainland states of Australia, and…

Auditory icons caricatures of everyday sounds have the potential to convey information by non-verbal means quickly and accurately. Two experiments investigated the application of auditory icons as warning signals to the civil aviation cockpit environment. Warning signals that are iconic and that stand in a direct relation to the event being signalled, such as the sound of coughing to signal the presence of carbon monoxide, should convey information about the nature of the critical event as well as alerting the operator that there is a problem. By contrast, signals that are arbitrarily…