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Air Safety Investigation


Contact: Rob Lee (02) 6274 6431 Email: Rob.Lee@DOTARS.gov.au


  1. Safety Investigation

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The primary role of the Bureau of Air Safety Investigation (BASI) is the effective and timely investigation of aviation safety deficiencies and the proactive application of advanced new concepts of systems safety in line with world best-practice.

BASI investigates accidents, serious incidents, incidents and safety deficiencies involving civil aircraft operations in Australia and overseas, with a major concern being the safety of commercial air transport and fare-paying passengers.

BASI investigates and studies Australia's aviation system to identify and rectify underlying factors that affect air safety and have potential significance as accident factors. BASI also administers and maintains Australia's mandatory and confidential aviation occurrence reporting systems. On occasion BASI investigators are required to attend and participate in inquests, legal hearings and official inquiries.

In 1998-99, the Bureau completed a number of systemic investigations and safety program studies within Australia, including:

  • the investigation of a Saab 340 loss-of-control occurrence;
  • the investigation of the crash of a floatplane at Calabash Bay, New South Wales (NSW);
  • the investigation of the Class G airspace demonstration (report to be released in late 1999);
  • a study of the safety of regional airline operations; and
  • factors underlying air safety occurrences in the Sydney Terminal Area (TMA).

The Bureau was also involved in investigating accidents in the Asia-Pacific region, including:

  • assisting the Taiwan Aviation Safety Council in a fatal helicopter accident in Taiwan;
  • a Twin Otter (operated by the Australian Defence Force) accident in Papua New Guinea (PNG);
  • for the Vanuatu Government, a Twin Otter air transport accident near Port Vila involving three Australian citizens; and
  • for the PNG Government, a Bandeirante air transport accident in the PNG highlands resulting in 17 fatalities, including four Australian citizens.

Throughout the year, the Bureau:

  • continued to provide assistance in the readout and analysis of flight data and cockpit voice recordings for air transport carriers from several Asia-Pacific countries including Indonesia, Fiji, PNG, the Philippines, Taiwan, Malaysia, China and Singapore;
  • fulfilled an ongoing commitment to provide engineering and materials analysis of a number of aviation occurrences, both within Australia and overseas;
  • provided information and developed structured arrangements with various Australian and regional agencies for mutual cooperation in air safety investigation;
  • enhanced accident prevention by the prompt identification of safety deficiencies, the distribution of associated safety recommendations, and by the advancement of an Australian-Asia-Pacific safety culture through the exchange of safety information within the aviation industry;
  • allocated further resources to training newly appointed investigators and other BASI staff. The Bureau continued to improve its structured approach to the training and development of staff, aligned with divisional and departmental objectives, as part of the Department's successful program for '#145;Investors in People' accreditation. Replacement of experienced investigators added to training requirements; and
  • continued to be recognised internationally as a centre of excellence, due to its use and development of advanced system safety concepts and proactive safety programs directed to accident prevention.

BASI was the subject of two major reviews during the year:

  • an internal organisational review involved all staff and resulted in significant changes to its structure being implemented in March 1999; and
  • an external review, headed by Mr Paul McGrath, AM, former Chief Executive of the Australian Maritime Safety Authority, completed in July 1999 and released on 6 August 1999. The McGrath Review examined BASI's role, operations and effectiveness, and aspects of its relationships with other agencies involved in aviation safety.

There were 5729 air safety occurrences notified to the Bureau during 1998-99, representing a 35 per cent increase over the previous year.

During the year, the Bureau completed one major comprehensive systemic study - the Regional Airlines Safety Study Project. It also researched and issued 66 safety recommendations.

BASI concluded a Memorandum of Understanding with the Civil Aviation Authority of Singapore, relating to cooperation in the investigation of accidents and serious incidents, and with the Taipei Economic and Cultural Office in cooperation in aviation safety. Such arrangements serve to reinforce Australia's international obligations and provide direct benefits to air travellers to and from Australia.

A major BASI initiative was to host the Aviation Safety Research Information Exchange Meeting in December 1998. The meeting aimed to coordinate aviation research undertaken by various institutions and agencies within Australia.

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Ministerials, Questions on Notice, Briefings, Speeches

The Bureau processed seven Ministerials during the year and provided input to approximately 32 aviation-related Ministerial responses and answers to Questions on Notice.

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Occurrences recorded

During the year 5729 aviation occurrences were reported to the Bureau, made up of 207 accidents and 5522 incidents. Forty-five of the total, including three overseas occurrences, involved on-site investigations, the remainder being investigated in-house. The bulk of occurrences reported required no further investigation to expand on and/or substantiate the initially reported facts and did not, as individual occurrences, represent significant safety deficiencies. Collectively, however, their analysis provided a valuable means of monitoring trends and identifying potential areas of safety deficiencies meriting wider investigation.

Accident and incident investigations (domestic and overseas)

In 1998-99, the Bureau conducted several significant domestic and overseas investigations.


The investigation of a fatal accident on 26 July 1998 involving a Cessna 185 floatplane at Calabash Bay, NSW revealed organisational deficiencies in the operator, and in the safety regulation by the Civil Aviation Safety Authority (CASA). BASI consequently issued one interim recommendation and four final recommendations.

On 22 October 1998, CASA commenced the Class G Airspace Demonstration. Investigation of reported incident and trend-monitoring raised concerns within BASI over various aspects of the demonstration. In early November 1998, BASI established a special team of investigators to conduct a systemic investigation into the circumstances surrounding its introduction. Five recommendations relating to its termination and aspects of the management and oversight of airspace were promulgated on 8 December 1998. As a consequence, CASA terminated the demonstration on 13 December 1998. A final report is expected in late 1999.

The crew of a Saab 340 turboprop aircraft operated by a regional airline experienced a loss of control while operating in icing conditions. To date, the investigation of this occurrence has led to the issue of 11 interim safety recommendations, disseminated worldwide.

During the investigation of a Boeing B737 landing gear failure on 12 March 1999, a serious safety deficiency was identified. Five interim recommendations were issued: to the Boeing Aircraft Group, the US Federal Aviation Administration (FAA), Australian B737 operators, and CASA. As a result, the FAA subsequently issued an Airworthiness Directive to all B737 aircraft operators.


The Bureau investigated overseas accidents in Vanuatu, Taiwan and PNG at the request of the respective government agencies. A Bureau investigator also took part in investigating the crash of a Swissair MD-11 in Canada - part of the Bureau's program of major accident investigation training and institutional preparedness to deal with a major accident should one occur in Australia.

Continuing assistance was provided to Indonesian authorities in two ongoing major accident investigations involving a B737 and an A300 aircraft, and to Taiwanese authorities concerning an A300 aircraft crash at Taipei.

The Bureau's Technical Analysis section also assisted agencies in the Asia-Pacific region in the recovery and analysis of recorded flight data, and the analysis of aircraft structural failure. Flight data analyses (including computer graphic animation) were conducted in relation to a B737 landing incident in Malaysia, a B737 landing incident in Indonesia, a Saab 340 accident in Taiwan, and two Fokker F28 accidents in PNG. Aircraft structural failure analysis was conducted in relation to the in-flight breakup of a low-capacity air transport aircraft (Britten Norman Islander) in PNG.

Confidential Aviation Incident Reporting program

During 1998-99, the Confidential Aviation Incident Reporting (CAIR) program received 326 incident reports and issued 147 notifications of potential threats to aviation safety.

A proportionate increase in reports from air traffic service officers and pilots reflected concerns about the Class G airspace demonstration. Specific safety issues arising from CAIR reports were referred to CASA, Airservices Australia (Airservices), operators and other appropriate organisations for information and action.

Inquests, legal hearings, official inquiries

BASI investigators attended six Coronial inquests as expert witnesses in fatal accident investigations during 1998-99, providing '#145;statements to assist' and other professional assistance to three further inquests. They were also subpoenaed to attend as witnesses in two litigation cases. BASI also provided a submission to the McGrath Review.

Safety studies

Safety programs, safety data reports

A systemic investigation of factors underlying three air safety occurrences in Sydney TMA was completed during 1998-99. Safety deficiencies were identified, and the Bureau is monitoring the initiatives Airservices is implementing to address them.

Key issues raised in the Regional Airlines Safety Study conducted in 1997 received further analysis during the year, including flight operations and procedures, check and training, maintenance, cabin safety and air traffic services. Fifteen safety advisory notices, nine interim recommendations and two final recommendations were issued as a result of that additional analysis. Favourable responses to some safety outputs have already been received from relevant agencies, and the Bureau continues to monitor trends in particular areas.

The BASI-INDICATE (Identifying needed defences in the civil aviation transport environment) safety program continued to receive positive endorsement from the aviation industry within Australia and overseas. The program is designed to help operators proactively monitor their safety performance. Over 300 INDICATE packages (including implementation guidelines and program software) have been dispatched throughout Australia and overseas since the program's release in March 1998. Considerable work has also been undertaken to upgrade INDICATE software to ensure Year 2000 compliance. An unsecured version has been made available to companies wishing to modify the software program to suit their own requirements. INDICATE is available on the BASI website.

A proposed safety study involving the air safety implications of Year 2000 commenced but was subsequently incorporated into a broader Departmental study of the issues related to all transport modes. The Bureau participates in this study to ensure that air safety issues are adequately addressed. The study is a collaborative project involving key representatives of various transport industries.

A study for the period 1989-98 of accidents and incidents involving fuel starvation and fuel exhaustion is expected to be completed in late 1999. The analysis is intended to identify trends and to determine factors common to such types of occurrences. Recommendations to help prevent similar occurrences will be issued where appropriate. A report will be released by the end of 1999.

A review of the safety of charter operations in Australia for 1988-98 was commenced. Part of this review will examine the processes adopted by agencies to decide upon, manage and effect changes that may have had an impact on the safety of charter operations, and to compare the intended effects of any changes with their outcomes. The review will be completed and a report released by mid-2000.

Several safety studies are currently under consideration relating to issues of direct concern to fare-paying passenger operations, including operational and organisational aspects of air traffic services, flight operations, maintenance and cabin safety.

Provision of safety recommendations and safety advisory notices

During the year BASI issued 88 safety outputs comprising 69 recommendations (34 interim recommendations and 35 final recommendations) and 19 safety advisory notices, to CASA, Airservices, and the aviation industry. Seventy-seven outputs focused on safety deficiencies directly involving fare-paying passenger operations, with potential to enhance the safety of those operations.

Of the 69 recommendations, 33 responses were received. Twenty-four responses were accepted by the Bureau, two partially accepted, and seven are still under review. All seven responses from agencies other than CASA and Airservices were accepted. Eleven responses from CASA remain outstanding, including those related to two recommendations arising from the investigation of safety issues related to the Class G airspace trial, one from the investigation into landing gear problems of Boeing 737s, and five from the investigation of the fatal Cessna 185 accident at Calabash Bay. One response from Airservices remains outstanding. (Responses to safety advisory notices are not required from any agency.)

Nine recommendations of the 69 were issued as a result of the systemic investigation of factors underlying air safety occurrences in the Sydney TMA.

Five interim recommendations were issued as a result of the systemic investigation into the Class G airspace trial. In response to one of them, the trial terminated on 13 December 1998. CASA, Airservices and the Department of Transport and Regional Services are still considering the remaining recommendations.

Five interim recommendations were also issued arising from the investigation of a Boeing B737 landing gear failure at Melbourne on 12 March 1999.

Safety information

safety bulletins and safety deficiency reports

The Bureau published and distributed two issues of its Regional Airlines Safety Bulletin to approximately 50 operators and individuals. The bulletin covers a range of safety issues tailored to the needs of the regional airline industry. A reader survey conducted during the second half of 1998 found that it was meeting regional airline needs. Suggested changes have been incorporated in its most recent issue. Resource limitations restricted publication to two issues in 1998-99, but it is intended that quarterly publication will resume. The Bulletin is available on the BASI website.

Four issues of the Quarterly Safety Deficiency Report (QSDR) were prepared and distributed. Each report contained all recommendations, interim recommendations and safety advisory notices issued in the previous quarter to action agencies. Responses to any safety outputs received by the Bureau during that same quarter were also included. The QSDR is available on the BASI website.

Four issues of Asia-Pacific Air Safety were published, each distributed to approximately 63 500 recipients.

Published accident and incident reports

The Bureau published one major accident report (Calabash Bay investigation), and 124 general accident and incident reports.

Most accident and incident reports are available on the BASI website. The website is now the key vehicle for distributing aviation safety information, an average of 2400 pages downloaded daily in 1998-99.


During 1998-99, analyses of the Bureau's Systemic Incident Analysis Model (SIAM) data provided clear indications of which elements of the aviation system were being relied on to maintain the safe operation of the total system, and which areas of the system were most vulnerable. Critical areas for further systemic safety study have been identified.

Responses to other bodies

The Bureau responded to 2135 requests (an average of 41 requests per week) from industry, government agencies, the media and the public for air safety occurrence reports and related safety information.

Seminars, conferences and working groups

The role of BASI in disseminating safety information includes regular attendance and presentations at seminars, conferences and working groups in Australia and overseas. BASI staff visit industry, companies and organisations for liaison and educational purposes, and participate in the annual Flight Safety Forums coordinated by CASA. In 1998-99, BASI delivered more than 40 public presentations and represented the Bureau at 14 national and international forums.

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Click here to visit BASI Review

The Minister for Transport and Regional Services announced on 9 February 1999 terms of reference for an independent review of the Bureau of Air Safety Investigation.

The review team, headed by Paul McGrath, AM, reviewed the efficiency and role of BASI. Against the background of changes to aviation regulations and service provision over the past decade, the review considered whether:

  1. BASI makes the most effective possible contribution to the maintenance and enhancement of aviation safety;
  2. its activities are recognised, valued and supported by the aviation community - particularly those airlines, manufacturers and service providers involved in the carriage of fare-paying passengers;
  3. its processes for addressing aviation incidents and accidents, and framing its recommendations for action, make effective and timely use of resources;
  4. its safety investigation, response and prevention roles have changed or should change; and
  5. it has the necessary degree of independence.

In considering these five issues, the review took particular account of:

  • the balance in BASI activities between accident and incident investigation and proactive safety measures;
  • the relative thoroughness of and time-frames in which BASI provides reports and related recommendations on incidents and accidents;
  • means to improve responsiveness of the aviation industry, service providers and regulators to BASI safety recommendations; and
  • working arrangements between Airservices, CASA and BASI, and any current or potential overlap of roles.

The review team sought public submissions on the Terms of Reference through advertisements 13-19 March 1999 in major metropolitan newspapers. An Issues Paper was available from the review team and through the Department's website. The review team distributed approximately 200 copies of the Terms of Reference and Issues Paper to aviation industry stakeholders. Submissions closed on 23 April 1999. Sixty formal written and eight oral submissions were received.

The report and its recommendations on BASI's efficiency and role were released on 6 August 1999 and are available on the Australian Transport Safety Bureau's website.

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