The ATSB has found that a TransAdelaide passenger train passed a red stop signal last year, which placed it on a collision course with an interstate passenger train because of a combination of human error and sub-optimal procedures. The Australian Transport Safety Bureau has today released its final report into the investigation of the factors that contributed to TransAdelaide passenger train H307 passing signal 161, at the end of a platform at Adelaide Railway Station, while it was displaying a red stop aspect, (an event commonly referred to as 'Signal Passed at Danger' or SPAD), on 28 March…
The ATSB has found that a leakage of dangerous goods on board the Liberian registered container ship Kota Pahlawan, off the coast of Australia, on 16 June 2006, occurred because the dangerous goods were not packaged properly. The Australian Transport Safety Bureau investigation found that packaging deficiencies in similar past shipments of xanthates, the dangerous goods being shipped, were commonplace but not reported. It was also found that Kota Pahlawan transited the northern part of the Great Barrier Reef Inner Route before authorities made an appropriate risk assessment. On the morning of…
ATSB analysis shows that an increase in reported airline accident and incident data since 2001 is mainly due to industry expansion, and the rates of many types of occurrence have fallen. The Australian Transport Safety Bureau research report released today covered more serious airline Immediately Reportable Matters in the 5 years from mid 2001 to mid 2006. Despite the increased activity in scheduled public transport operations, the number of Immediately Reportable Matters has generally either remained stable or declined. When measured in relation to airline activity, the trend rate is…
An ATSB research report released today examines the problem of spatial disorientation. Flying an aircraft is a challenging activity that exposes pilots to many potential hazards. One of the most significant of these is spatial disorientation. Spatial disorientation is a condition where the pilot is unable to correctly interpret aircraft attitude, altitude or airspeed in relation to the Earth. The resulting disorientation can lead to a loss of control of the aircraft. Spatial disorientation is a very common problem. It is vitally important that pilots are aware that it can affect any pilot,…
The Australian Transport Safety Bureau has found that heavy fog and the inappropriate speed of a truck in the conditions were the main contributors to a collision with a freight train at the Lismore Skipton Road level crossing at Lismore, Victoria on 25 May 2006. The 34 year old driver of the truck was fatally injured in the accident which closed the main Adelaide to Melbourne rail line for a period of six days with the total damage bill estimated at $13.5 million. The collision occurred when the truck drove into the side of the second locomotive while the train was on the level crossing.…
The ATSB has found that an undetected flaw, and the subsequent failure of a critical main engine component, led to the bulk carrier Enterprise being disabled in Bass Strait on 10 July 2006 and drifting for nearly three days. The Australian Transport Safety Bureau investigation has found that a microscopic flaw led to the failure of a main engine gudgeon pin. The investigation also found that the engine manufacturer did not provide sufficient guidance for monitoring the fatigue life of gudgeon pins and that the planning and execution of maintenance on critical items of equipment was inadequate…
The ATSB has found that a collision between a freight train and motor car occurred because the flashing lights, bells and boom gates failed to operate as the train approached the level crossing. The Australian Transport Safety Bureau has today released its final report into the investigation of a collision that occurred at the Chapple Street level crossing at Kalgoorlie in Western Australia on 14 May 2007. At the time of the collision the Chapple Street level crossing was controlled by flashing lights, bells and boom gates. The investigation established that the level crossing protection…
Failure to keep a proper lookout, a faulty radio and fatigue resulted in a collision between two vessels off the coast of Western Australian on 18 January 2001, according to an investigation report released by the Australian Transport Safety Bureau today. The report states that the collision occurred at 0435 local time, 14 miles off the coast when the rock lobster fishing vessel, Lipari, struck the side of the Hong Kong flag bulk carrier, Handymariner. The ship sustained no damage in the incident but the fishing vessel was holed on the starboard bow above the waterline. There were no injuries…
The Australian Transport Safety Bureau has released its final report after an almost two-year investigation of the systemic factors behind the groundings of Ansett B767 aircraft. While Ansett has ceased flying, the ATSB continued its investigation because of the importance of the issues involved for the safety of 'Class A' aircraft around the world. The ATSB found that in addition to errors and omissions by individuals in Ansett, there were deeper system and resource weaknesses in the airline group and shortcomings by the US regulator of the aircraft type (the FAA) both of which CASA was…
The first ATSB graduates from the recently accredited Diploma of Transport Safety Investigation were presented with their awards on 18 October 2002. Senior ATSB investigators Alan Stray, Kit Filor and Kerryn Macaulay received their Diplomas after successfully completing the streamlined assessment process aimed at recognising prior learning and current competency. Awards were also made to 12 staff who successfully completed a Certificate Level 4 course in Assessment and Workplace Training. This qualifies them to train and assess at the Diploma level. The awards are the first since the Bureau…