The ATSB Annual Report 2021-22 outlines performance against the outcome and program structure in the Department of Infrastructure, Transport, Regional Development, Communications and the Arts' Portfolio Budget Statements 2021–22 I am pleased to be able to introduce this annual report on the ATSB activities for 2021–22, a year that continued to present challenges not just for the agency but for the transport sectors we serve due to the ongoing COVID-19 pandemic as well as challenging economic circumstances. I commenced my term as Chief Commissioner and Chief Executive…

Safety Advisory Notice To Beechcraft Baron operators Beechcraft Baron heater fuel supply line inspection The ATSB is encouraging Baron operators to inspect the heater fuel supply line and nearby wiring in the aircraft cockpit to reduce the risk of an in-flight fire. What happened At approximately 0835 on the morning of 16 April 2022, the pilot of a Beechcraft B58 Baron registered VH-NPT commenced an approach to Runway 12 at the East Kimberley Regional Airport near Kununurra. Upon selection of the landing gear to the down position the pilot reported multiple unusual…

Safety Advisory Notice To Rollingstock Operators Number: RO-2020-022-SAN-002 Unknown functions in locomotive braking systems An ongoing investigation, conducted by NSW’s Office of Transport Safety Investigations on behalf of the Australian Transport Safety Bureau, highlights risks associated with misunderstood functionality of locomotive braking systems. Locomotive drivers require a clear understanding of the braking systems on all the locomotives they are operating. What happened On 15 December 2020 a loaded grain train derailed whilst descending…

Safety Advisory Notice A correctly fitted and secured flight helmet can significantly reduce injuries and save lives in the event of a serious incident or accident. But a helmet is only fully effective if it is fitted correctly, retained securely on the wearer’s head, and maintained in accordance with the manufacturer’s instructions. Source: ATSB What happened On 31 July 2020, the pilot of a Robinson R44 helicopter was conducting aerial spraying along a property fence line. During the fifth spray load, as the helicopter descended from above trees to recommence spraying, it…

Safety Advisory Notice Loss of drive to the main rotor system What happened On 14 February 2022, the pilot of a Garlick Helicopters UH-1H was providing aerial firefighting support to combat the ‘Labrina’ bushfire that had developed north of Launceston, Tasmania. That afternoon, the pilot was tasked to firebomb a localised hot-spot that had developed within the fireground. Witnesses both on the ground, and within a nearby helicopter, observed the early release of the water load from the underslung bucket, before the UH-1H commenced a left turn and descended toward nearby open…

Safety Advisory Notice Delayed flight crew responses can lead to hazardous high-speed rejected take-offs or flight with unreliable airspeed indications. What happened On the night of 18 July 2018, an Airbus A330 commenced take-off from Brisbane, Queensland with covers left on the aircraft’s three pitot probes (airspeed sensors). The primary flight displays showed red speed flags in place of the airspeed indication early in the take‑off, and either speed flags or unrealistically low airspeeds for the remainder of the flight. The standby airspeed display was also invalid…

Safety Advisory Notice To aerobatic pilots and instructors All aircraft types do not spin and recover in the same way. Know your aeroplane type, what recovery techniques will work and what recovery techniques will not work. What happened On 23 June 2021, while conducting spin entry and recovery training from 5,800 ft above ground level, the Cessna A150M Aerobat did not fully recover from a spin to the left before impacting terrain. Factors uncovered during the investigation The aerobatics instructor was experienced in conducting spins, primarily in the Pitts Special aircraft type…

I am pleased to present the Australian Transport Safety Bureau’s (ATSB) Corporate Plan, which covers the period 2020-2021 to 2023-24. This version of the Corporate Plan, issued in March 2021, is a minor variation of the original plan. I acknowledge this is a time of great uncertainty for the transport industry in general, and aviation in particular. Many ATSB investigators and operational support staff have come from the aviation, rail and marine transport modes and continue to maintain strong industry links. We have great empathy for operators and their respective workforces who are facing…

Carbon monoxide (CO) is a colourless, odourless and tasteless gas found in the exhaust gases of piston‑engine aircraft. Carbon monoxide detectors provide warning to aircraft occupants of the presence of CO levels in the cabin that are above safe concentrations. What happened On the afternoon of 31 December 2017, the pilot and five passengers of a DHC-2 Beaver floatplane, registered VH-NOO, boarded the aircraft for a charter flight from Cottage Point to Rose Bay, New South Wales. The aircraft taxied for about 7 minutes. Shortly after take-off, the aircraft deviated from the standard flight…

Safety summary Update This statistical report shows aviation occurrence and activity data over the 10-year period from 2010–2019 to provide an insight into current and possible future trends in aviation safety. The previous edition (AR‑2020‑014) published in April 2020 presented 10 years of occurrence data, but aviation activity data was only available for 2014–2018 as 2019 activity data was not available at the time of publishing. This report is an update of the previous edition with the addition 2019 aviation activity data which also allows all occurrence rates to be presented for the…