Flying in Australia still very safe - ATSB Review 2008

The Australian Transport Safety Bureau (ATSB) released its Annual Review 2008 on 31 October 2008, reporting on the 2007-08 financial year of all its operations including Aviation.

The ATSB’s Aviation Investigation Branch investigates accidents and other occurrences involving civil aircraft in Australia in accordance with Annex 13 to the Convention on International Aviation (Chicago Convention 1944) which has legal force in Australia by operation of the Transport Safety Investigation Act 2003 (Cth).

The purpose of ATSB aviation investigations is to enhance aviation safety by determining the factors and associated safety issues which contribute to accidents and incidents in order to assist in preventing similar occurrences in the future. The ATSB works with the Civil Aviation Safety Authority (CASA), Airservices Australia, aircraft manufactures and operators, who are best placed to effect changes to improve safety.

The statistics reported show that in 2007-08:

  1. The ATSB initiated 77 new aviation investigations from approximately 15,218 notifications received (8,299 were recorded as aviation occurrences);
  2. The ATSB completed 73 aviation investigations down from 80 in 2006-07;
  3. The median time for investigations was 443 days, an increase from 379 days last year and well above the target of 365 days;
  4. There were 131 separately identified safety actions taken by aviation safety stakeholders in response to 43 different aviation investigations;
  5. The completed investigation reports included a total of 23 safety recommendations and two safety advisory notices to aviation stakeholders;
  6. At 30 June 2008, the ATSB was continuing with 91 aviation investigations up from 87 in 2006-07.

 

The ATSB reported that the key aviation investigations completed in 2007-08 included;

  1. Boeing 737-476 in-flight engine malfunction 6 km SSE Sydney, NSW, 25 August 2005. The investigation  revealed that a single dowel pin had come loose from its installed position within stage three of the high pressure compressor (HPC) and was ingested by the downstream rotating hardware, resulting in damage to the HPC rotor and stator components. As a result, the engine manufacturer initiated a number of safety actions that included a redesign of the HPC anti-rotation pin and release of a Service Bulletin to all operators that recommended the introduction of the new pin design.
  2. VH-SEF Fairchild Metro III fuel exhaustion 18 km SW Bundaberg, QLD, 23 September 2005.  The investigation determined that problems with the aircraft’s fuel quantity-indicating system and limitations in the company’s flight crew practices relating to fuel quantity resulted in the aircraft departing Brisbane with only 65% of the amount of fuel the crew believed was on board. The investigation found a number of safety factors that contributed to the fuel quantity system over-reading and leading to the usable fuel in the left tank being exhausted. Following the occurrence, the operator developed new procedures for fuel quantity management and CASA made rule changes regarding fuel quantity measurement and verification for transport category aircraft.
  3. VH-UTB Cessna U206 collision with terrain near Willowbank, QLD, 2 January 2006. Shortly after take off, the engine lost power and the aircraft crashed into a tree, coming to rest in a dam with 5 of the 7 passengers killed. Technical examination and testing of the aircraft’s engine and its associated components did not reveal any anomalies with the potential to have individually contributed to the partial engine power loss. As a result of the investigation, the Australian Parachute Federation addressed a number of safety concerns, CASA initiated safety action including a review of the various training syllabi affecting the management of engine and partial engine power loss after take off. The ATSB issued 7 safety recommendations related to airworthiness bulletins, regulations, parachutists’ safety and survivability, aircraft maintenance documentation and pilot training in emergency procedures.
  4. VH-AKY BAC Strikemaster in-flight breakup 20 km NE Bathurst, NSW, 5 October 2006. The aircraft impacted with the ground and the pilot and passenger were killed. At the time of impact the engine was producing significant power and the wing flaps and landing gear were retracted. The right wing and tail had separated from the aircraft. ATSB’s analysis revealed that the separation of the right ring was precipitated by pre-existing fatigue cracking in the right wing upper main spar attachment lug. Examination of the recovered items of the tail section and assessment of the distribution of the items indicated that the rudder mass balance was torn off over the top of the rudder at an early stage of the breakup sequence. The majority of the available evidence was consistent with a breakup initiated by separation of the tail surfaces leading to the separation of the weakened right wing. The ATSB briefed CASA and the UK Civil Aviation Authority (CAA) on the findings, CASA released a number of Airworthiness Bulletins, and the CAA issued a Mandatory Permit Directive.

 

The ATSB also attended the following Coronial Inquests in 2007-08 requiring considerable resources of its investigators for both the preparation and attendance:

  1. Lockhart River coronial inquest - May 2005;
  2. VH-ZIP Cessna 188B fatal accident - March 2006;
  3. Lancair fatal accident at Bankstown - April 2006; and
  4. Cessna U206, VH-UYB fatal accident - January 2006.

The Report provides Transport Safety Performance Statistics of the major transport modes from 1998 to 2007. Between 2003 to 2007, road accidents accounted for 94% of the total fatalities, with Rail, Marine, and Aviation accounting for approximately 2% each. The overall death rate across all modes of transport decreased from 10.14 deaths per 100,000 population in 1998 to 7.89 in 2007.

For aviation reported incidents, the statistics show that high-capacity aircraft (regular public transport aircraft greater than 38 seats or maximum payload exceeding of 4,200 kg) operations continue to be the safest in the country, with extremely low accident numbers. To date, Australia has recorded no hull losses or fatal accidents involving high-capacity aircraft. Low-capacity aircraft (regular public transport aircraft with 38 seats or less or a maximum payload of 4,200 kg) continue to very safe in terms of the number of accidents with two fatal accidents (Whyalla accident in 2000 with 8 fatalities and Lockhart River in 2005 with 15 fatalities).

Of the general aviation categories, private operations continue to dominate the statistics with 555 non fatal accidents and 89 fatal between 1998 and 2007, followed by aerial work 332 non fatal and 31 fatal, flying training 209 non fatal and 13 fatal, and business 25 non fatal and 7 fatal. However, there has been an overall decrease in annual accident numbers since 1998. With respect to recreational aviation which includes ballooning, gliding, and sports aviation, there were 3 fatal accidents and 7 non fatal in 2007 and over a ten year period from 1998 to 2007, 28 fatal accidents are recorded and 71 non fatal accidents.

The statistics when measured against the amount of flying each category of operation has undertaken shows a decline in accidents in the period 1997 to 2006 and variations in fatalities arising from fatal accidents which remain extremely low for high and low capacity operations. For general aviation operations there is also an overall decrease in accident rates in the period 1997 to 2006 compared to a small overall increase in the fatal accident and fatality rate.

International aviation comparison shows that Australia had the lowest accident rate for high capacity aircraft in the world for the period 2003 to 2007. Australia recorded 0.0 accidents per million departures (based on hull losses) against a world average of 0.5 accidents per million departures, with Africa recording the highest at 4.5 accidents per million departures.

The ATSB report is encouraging in that it indicates Australia’s high and low capacity aviation operators are very safe and have very low accident rates compared to the rest of the world. This suggests that all those involved in aviation through to the regulator are continuing to be effective in ensuring the safety of aviation operations. In addition there is a clear decrease in the number of accidents reported in both air transport and general aviation with a consistent low fatal accident rate.

The next ATSB report for 2008-09 will be an interesting comparison with two recent high capacity aircraft non fatal incidents and a number of general aviation fatal accidents having already occurred this year. Looking ahead in the 2008-09 year, the ATSB plans to commence and conduct up to 80 aviation investigations, and complete about 10 aviation research and analysis reports focussing on safety priorities, occurrence trends and human factors issues. The ATSB also participated in a review of the provisions of Annex 13 to the Convention on International Civil Aviation at the ICAO Accident Investigation and Prevention Divisional Meeting in October 2008. The ATSB will also contribute input to the Government’s announced Green and White paper process on aviation which will also pick up some of the suggestions made by the 2007 Miller Review, which examined the relationship between the ATSB and CASA.

While the indications are that flying remains a very safe pastime in Australia, whether of the joy flight or regular public transport category, accidents still occur and there is no room for complacency.

 

Author: Matthew Brooks