Coronial investigations and inquests are different to ATSB safety investigations, with different objectives and evidentiary requirements. It is important that the ATSB works closely with coronial officers and the police as early as possible in an investigation. While ATSB investigations and coronial inquests are separate processes, they share a similar important objective: to prevent a similar death occurring in the future. This page outlines how the ATSB can work in parallel with coronial officers and the police. It also explains the ATSB's legal limitations on releasing evidence from an…

The Human Factors Analysis and Classification System (HFACS) is a hierarchical taxonomy that describes the human factors that contribute to an aviation accident or incident that is based on a chain of- events theory of accident causation and was derived from Reason's (1990) accident model. The objectives of this exploratory study were to identify relationships between the factors of the HFACS taxonomy and to assess the usefulness of HFACS as a predictive tool. The associations found in this study may assist investigators in looking for associated factors when contributing factors are found.…

This report documents the number and types of safety occurrences involving loading of high capacity aircraft across a 7-year period to raise awareness within the aviation industry of the associated issues. Incorrect loading of containers, pallets or bags into aircraft can result in them being outside of weight or centre of gravity operating limits, and this may influence aircraft controllability. Most high capacity aircraft loading occurrences are relatively minor, with cargo locks not being raised being the most common. More serious occurrences have involved shifting cargo and unlisted cargo…

This report tables rail safety occurrence data by state and territory between 1 January 2001 and 31 December 2010. Data is adjusted biannually to reflect new information that comes to light during the reporting period. There is a lag period of approximately 3 to 4 months between the end of the 6-monthly reporting period and publication of this data. The data is presented as counts, and normalised using kilometres travelled and number of track kilometres. Data presented in this report conforms to ON-S1: Occurrence Notification Standard 1 (2004) and OC-G1: Occurrence Classification…

The ATSB receives around 15,000 notifications of aviation occurrences each year; 8,000 of which are accidents, serious incidents and incidents. It is from the information provided in these notifications that the ATSB makes a decision on whether or not to investigate. While further information is sought in some cases to assist in making those decisions, resource constraints dictate that a significant amount of professional judgement needs to be exercised. There are times when more detailed information about the circumstances of the occurrence would have allowed the ATSB to make a more informed…

The ATSB receives around 15,000 notifications of aviation occurrences each year; 8,000 of which are accidents, serious incidents and incidents. It is from the information provided in these notifications that the ATSB makes a decision on whether or not to investigate. While further information is sought in some cases to assist in making those decisions, resource constraints dictate that a significant amount of professional judgement needs to be exercised. There are times when more detailed information about the circumstances of the occurrence would have allowed the ATSB to make a more informed…

In the 2009-2010 financial year, the Australian Transport Safety Bureau (ATSB) completed 37 aviation, 10 marine, and 11 rail investigations where safety factors were identified using the ATSB analysis framework. From these investigations, 124 safety issues (factors that have a potential to adversely affect the safety of future operations) were identified and 141 safety actions were undertaken to address these safety issues. This report documents and analyses these safety issues and safety actions and explores the risk levels assigned to provide an understanding of where the greatest risks to…

Everyday errors such as incorrectly transcribing or inadvertently dialling a wrong telephone number normally have minimal consequences. For high-capacity aircraft operation, the consequence of such errors can be significant. There have been numerous take-off accidents worldwide that were the result of a simple data calculation or entry error by the flight crew. This report documents 20 international and 11 Australian accidents and incidents (occurrences) identified between 1 January 1989 and 30 June 2009 where the calculation and entry of erroneous take-off performance parameters, such as…

The ATSB receives around 15,000 notifications of aviation occurrences each year; 8,000 of which are accidents, serious incidents and incidents. It is from the information provided in these notifications that the ATSB makes a decision on whether or not to investigate. While further information is sought in some cases to assist in making those decisions, resource constraints dictate that a significant amount of professional judgement needs to be exercised. There are times when more detailed information about the circumstances of the occurrence would have allowed the ATSB to make a more informed…

One passenger was fatally injured when a helicopter crashed in bad weather near Cairns last year. At 1130 on 12 March 1999 the Bell 206L-3 helicopter departed from Green Island on a routine passenger charter flight to Cairns airport. The helicopter took off in light drizzle and the pilot elected to track back to The Pier via the shipping channel. The Bureau of Meteorology had issued an amended aerodrome forecast for Cairns at 0808 for the 24-hour period from 1000. It forecast an easterly wind at 15 knots, visibility of 9,000 metres and light rain. Some cloud patches were expected with a base…