Deciding whether to investigate
This section provides information on the decision process for
investigating a transport safety matter.
Background
The ATSB is resourced each year to undertake a finite number of
investigations. It is acknowledged, however, that an occurrence
with a large number of passenger fatalities would represent a major
accident that may require supplementary funding.
Following the initial assessment of a notification, a decision
is made whether or not to conduct an investigation.
Full investigations are classified on a scale of 1-4. An occurrence may also
be subject to a limited scope Short fact gathering
investigation Level 5, Short Investigation
Bulletins. Refer to the investigation levels in Classifying.
Priorities for investigating
The ATSB's primary focus is on enhancing safety with respect to
fare paying passengers, and in particular, those transport safety
matters that may present a significant threat to public safety and
are the subject of widespread public interest. The ATSB therefore
needs to direct significant attention to identifying systemic
failures in aviation, marine and rail mass public transport
systems, that have the potential to result in catastrophic
accidents and which are often characterised by large numbers of
fatalities and serious injuries.
In addition, the ATSB has observed that many accidents involve
repetition of past occurrences where the contributing factors are
similar and the safety issues are well known. In these
circumstances, the likely safety benefits and lessons may not
always justify allocating significant resources. In those cases,
the ATSB may undertake a limited fact-gathering investigation only;
if so, it will outline the reasons an extensive investigation has
not been conducted. Equally, there is often as much or more to be
learned from serious incidents or patterns of incident as there is
from accidents and where appropriate, the ATSB will give priority
to these sorts of investigation.
The following broad hierarchies for aviation, marine and rail
which reflect the priorities described above, must be taken into
account when deciding whether to investigate and when determining
the level of investigation response.
Aviation broad hierarchy
In applying these guidelines, the ATSB will allocate its
resources in line with the following broad hierarchy of operation
types:
1. Passenger transport - large aircraft.
2. Passenger transport - small aircraft:
- RPT and charter on small aircraft
- humanitarian aerial work (for example, RFDS, SAR flights).
3. Commercial (that is, fare paying) recreation
(for example, joy flights).
4. Aerial work with participating passengers (for
example, news reporters, geological surveys).
5. Flying training.
6. Other aerial work:
- non-passenger carrying aerial work (for example, agriculture,
cargo)
- private transport/personal business.
7. High risk personal recreation/sports
aviation/experimental aircraft operations.
Marine broad hierarchy
In applying these guidelines, the ATSB will allocate its
resources in line with the following broad hierarchy of marine
operation types:
1. Passenger operations.
2. Freight and other commercial operations.
3. Non-commercial operations.
Rail broad hierarchy
In applying these guidelines, the ATSB will allocate its
resources in line with the following broad hierarchy of rail
operation types:
1. Mainline operations that impact on passenger
services.
2. Freight and other commercial operations.
3. Non-commercial operations.
Level of response
The level of investigation response is determined by resource
availability and such factors as detailed below. These factors are
presented in no particular order and may, depending on the
circumstances, vary in the degree to which they influence the
ATSB's decision to investigate and the level of response.
• anticipated safety value of an investigation, including the
likelihood of furthering the understanding of the scope and impact
of any safety system failures
• likelihood of safety action arising from the investigation,
particularly of national or global significance
• existence and extent of fatalities/serious injuries and/or
structural damage to transport vehicles/other infrastructure
• obligations or recommendations under international conventions
and/or codes
• nature and extent of public, interest, in particular the
potential impact on public confidence in the safety of the
transport system
• existence of supporting evidence or requirements to conduct a
special investigation based on trends
• relevance to an identified and targeted safety program
• the extent of resources available and projected to be available
in the event of conflicting priorities
• the risks associated with not investigating including
consideration of whether, in the absence of an ATSB investigation,
a credible safety investigation by another party is likely
• timeliness of notification
• training benefit for ATSB investigators.
Initiation of an investigation
With increasing resource pressure, initiation of a full
investigation under s21(1) of the TSI Act can only be done by the
relevant Team Leader in consultation with the Director, the Deputy
CEO and Chief Commissioner.
Level 5 fact gathering investigations can be initiated by the
relevant Director.
Occurrences that require a full investigation are initially
classified as Level 4 (see Classifying for a
description of each investigation level) unless agreed to be above
this level at the outset. Any upgrading in level (with accompanying
resource commitment) must be authorised by the relevant Director in
consultation with the Deputy CEO and Chief Commissioner.
Fatal accidents not investigated
The ATSB's justification for electing not to investigate a
notifiable fatal accident will be documented in the database record
for that occurrence.
Trend monitoring
Occurrences that may fit the definition of an aviation safety
accident or incident but that in isolation do not represent a risk
to safe aviation, do not require individual investigation.
Such occurrences may be referenced during trend monitoring of
occurrences with similar factors. These are Level 5-Data Entry
occurrences.
Marine and rail do not have the same weight in numbers for trend
monitoring, although the Team Leaders monitor obvious trends in
accidents in the industry which forms a part of the decision making
process to decide whether or not to investigate.
Classifying
This section provides information on the classification
process.
Introduction
The objective of the classification process is to quickly
identify and manage appropriately, including the allocation of
resources, those occurrences that:
• require detailed investigation
• need to be recorded by the ATSB for future research and
statistical analysis
• need to be passed to other agencies for further action
• do not contribute to transport safety.
Three ways to action
Transport safety matter reports can be actioned in one of three
ways to contribute to the Bureau's functions.
1. A report of an occurrence that suggests that
a safety issue may exist should be investigated immediately.
Investigation may lead to the identification of the safety issue,
including its significance, and provide the justification for
safety action.
2. A report of an occurrence that may not
warrant a full investigation but which would benefit from
additional fact gathering for future safety analysis to identify
safety issues or safety trends.
3. Basic details of an occurrence, based
primarily on the details provided in the initial occurrence
notification, can be recorded in the database to be used in future
safety analysis to identify safety issues or safety trends.
Note: In the third approach, the occurrence is
not investigated immediately, but may be the subject of a future
investigation.
Pros/cons first approach
The advantages of the first approach are a quick identification
of a safety issue, and a thorough investigation of all the data
relating to the occurrence.
The disadvantage in this approach is that a full investigation
uses considerable resources and time.
Pros and cons of the second approach
The advantage of the second approach is that a richer data set
for a greater number of occurrences is generated with minimal
resource overhead which, in turn, is likely to result in improved
future research and statistical analysis outcomes. These short,
fact gathering investigations also provide an opportunity to
upgrade to a full investigation when the initial fact gathering
suggests that the issues are more complex and warrant more detailed
examination and analysis.
Pros/cons third approach
The advantage of the third approach is that it can be used for a
large number of occurrences using far fewer resources than the
first two approaches.
The major disadvantage is that a safety issue may not be
identified until after a considerable period of time.
Who classifies?
With aviation, classifying a transport safety matter is normally
the task of the Notifications Officer; however, the Team Leader
Notification and Confidential Reporting needs to liaise with the
relevant Team Leader or Director.
Marine and rail notification classification is the
responsibility of the relevant Team Leader.
The investigation levels
Investigations are classified by the level of resources and/or
the complexity and time required to complete the investigation-the
levels are 1 to 6.
The list below describes the transport safety investigation
levels used by the ATSB.
Level 1
• likely to involve the majority of ATSB resources, in addition to
significant external resources, for up to 24 months
• likely to require additional one-off Government funding
Level 2
• involves a large number of ATSB and possibly external resources
and/or
• scale and complexity of which usually requires up to 18 months
to complete
Level 3
• involves in-the-field activity, several ATSB and possibly
external resources and/or
• scale and complexity of which usually requires up to 12 months
to complete
Level
4
• a less complex investigation which requires no more than 9
months to complete (may at times be a 'desktop' exercise requiring
no in-the-field activity) and/or
• involves only one or two ATSB resources
Level 5
Represents a transport safety matter under the TSI Act but which
has been assessed as either:
• Level 5 (short) - limited scope factual information only based
investigations, which result in a short summary report of 1 to 2
pages. Generally completed within 4 to 6 weeks and published
quarterly. Requires only one ATSB resource.
• Level 5 (data entry) - not requiring an investigation. The
unverified information is entered into relevant databases for
statistical purposes.
Level 6
Not a transport safety matter by definition of the TSI Act.
ATSB controlled accident
sites
The Australian Transport Safety Bureau is responsible for
ensuring the occupational health and safety of personnel entering
accident sites which it controls. Recent on-site accident
investigations have brought to our attention that some personnel
wishing to enter accident sites are not appropriately or adequately
equipped to be on the site.
In exercising our duty of care and in ensuring compliance with
the Occupational Health and Safety
(Commonwealth Employment) Act 1991, you are informed that
should your personnel wish to enter an ATSB controlled accident
site they must be appropriately equipped and have a record of
inoculations.
Dependent on the hazardous nature of the site, personnel may
also be required to provide evidence of having completed of a
Bio-Hazard Awareness course, which is accepted by the USA Federal
Aviation Administration or the ATSB, before being permitted to
handle anything on the site. The ATSB recognises that some aviation
professionals may have legitimate reasons for wishing to enter
accident sites. The ATSB will, as far as possible, accommodate such
requests, but has the ultimate decision over accident sites under
its control.
The following minimum current vaccination
record is required:
- Hepatitis B
- Tetanus toxoid
The following minimum Personal Protective
Equipment is required:
- Boots steel toed
- Overalls including disposable overalls
- Boot covers or gumboots (preferably steel toed)
- Latex/Nitrile/Rubber Gloves
- Leather riggers gloves
- Safety Glasses/Goggles/Face Shield
- Hearing Protection (Ear plugs)
- Hard hat
- Breathing protection apparatus
- Breathing apparatus needed may range from paper nose and mouth
guard, to a respiratory mask meeting the Australian Standard
AS1716.
Some sites may be contaminated by bio-hazards. Accordingly, in
such cases the investigator in charge has a duty of care to require
evidence of successful completion of a Blood Borne Pathegons
bio-hazard course approved by either the US Federal Aviation
Administration or the ATSB before allowing anyone onto an ATSB
controlled site.
These requirements are necessary to ensure that the ATSB meets
its statutory obligations under the Occupational Health and Safety
(Commonwealth Employment) Act 1991.
Section 17 states:
An employer must take all reasonable practicable steps to
ensure that persons at or near a workplace under the employer's
control who are not the employer's employees or contractors are not
exposed to risk to their health or safety arising from the conduct
of the employer's undertaking.
Penalty: In the case of a Government business enterprise -
$100,000.
Purpose of safety
investigations
The ATSB is responsible for investigating accidents and other
transport safety matters involving civil aviation, marine and rail
operations in Australia that fall within Commonwealth jurisdiction,
as well as participating in overseas investigations involving
Australian registered aircraft and ships. A primary concern is the
safety of commercial transport, with particular regard to
fare-paying passenger operations. The ATSB performs its functions
in accordance with the provisions of the Transport Safety
Investigation Act 2003 and Regulations and, where
applicable, relevant international agreements.
The object of a safety investigation is to identify and reduce
safety-related risk. ATSB investigations determine and communicate
the safety factors related to the transport safety matter being
investigated. The terms the ATSB uses to refer to key safety and
risk concepts are set out in the section: Terminology
Used in this Report.
It is not a function of the ATSB to apportion blame or determine
liability. At the same time, an investigation report must include
factual material of sufficient weight to support the analysis and
findings. At all times the ATSB endeavours to balance the use of
material that could imply adverse comment with the need to properly
explain what happened, and why, in a fair and unbiased manner.
Developing safety action
Central to the ATSB's investigation of transport safety matters
is the early identification of safety issues in the transport
environment. The ATSB prefers to encourage the relevant
organisation(s) to initiate proactive safety action that addresses
safety issues. Nevertheless, the ATSB may use its power to make a
formal safety recommendation either during or at the end of an
investigation, depending on the level of risk associated with a
safety issue and the extent of corrective action undertaken by the
relevant organisation.
When safety recommendations are issued, they focus on clearly
describing the safety issue of concern, rather than providing
instructions or opinions on a preferred method of corrective
action. As with equivalent overseas organisations, the ATSB has no
power to enforce the implementation of its recommendations. It is a
matter for the body to which an ATSB recommendation is directed to
assess the costs and benefits of any particular means of addressing
a safety issue.
When the ATSB issues a safety recommendation to a person,
organisation or agency, they must provide a written response within
90 days. That response must indicate whether they accept the
recommendation, any reasons for not accepting part or all of the
recommendation, and details of any proposed safety action to give
effect to the recommendation.
The ATSB can also issue safety advisory notices suggesting that
an organisation or an industry sector consider a safety issue and
take action where it believes it appropriate. There is no
requirement for a formal response to an advisory notice, although
the ATSB will publish any response it receives.
How ATSB safety
investigation reports are organised
ATSB investigation reports are organised in accordance with
international standards or instruments, as applicable, and with
ATSB procedures and guidelines. Reports normally contain the
following main parts:
Part 1: Factual information
Provides objective information that is pertinent to the
understanding of the circumstances surrounding the occurrence
Part 2: Analysis
Discusses and evaluates the factual information presented in Part
1 that the ATSB considered when determining its findings and safety
actions.
Part 3: Findings
Based on the analysis of the factual information, presents three
categories of findings; contributing safety factors; other safety
factors; and other key findings.
Part 4: Safety action
Based on the findings of the investigation, records the main local
actions already taken or being taken by the stakeholders involved,
and recommends safety actions required to be taken to eliminate or
mitigate safety issues.
Part 5: Appendixes
Contains additional information that supports the report, for
example, specialist reports on materials failure or flight data
analysis.
Note: Not all parts described above will be
applicable in all circumstances. Reports of less complex
investigations, for example, may not include safety action or
appendixes.
Terminology used in ATSB
safety investigation reports
Occurrence: accident or incident.
Safety factor: an event or condition that
increases safety risk. In other words, it is something that, if it
occurred in the future, would increase the likelihood of an
occurrence, and/or the severity of the adverse consequences
associated with an occurrence. Safety factors include the
occurrence events (e.g. engine failure, signal passed at danger,
grounding), individual actions (e.g. errors and violations), local
conditions, current risk controls and organisational
influences.
Contributing safety factor: a safety factor
that, had it not occurred or existed at the time of an occurrence,
then either:
(a) the occurrence would probably not have occurred; or
(b) the adverse consequences associated with the occurrence would
probably not have occurred or have been as serious, or
(c) another contributing safety factor would probably not have
occurred or existed.
Other safety factor: a safety factor identified
during an occurrence investigation which did not meet the
definition of contributing safety factor but was still considered
to be important to communicate in an investigation report in the
interests of improved transport safety.
Other key finding: any finding, other than that
associated with safety factors, considered important to include in
an investigation report. Such findings may resolve ambiguity or
controversy, describe possible scenarios or safety factors when
firm safety factor findings were not able to be made, or note
events or conditions which 'saved the day' or played an important
role in reducing the risk associated with an occurrence.
Safety issue: a safety factor that:
(a) can reasonably be regarded as having the potential to
adversely affect the safety of future operations, and
(b) is a characteristic of an organisation or a system, rather
than a characteristic of a specific individual, or characteristic
of an operational environment at a specific point in time.
Risk level: The ATSB's assessment of the risk
level associated with a safety issue is noted in the Findings
section of the investigation report. It reflects the risk level as
it existed at the time of the occurrence. That risk level may
subsequently have been reduced as a result of safety actions taken
by individuals or organisations during the course of an
investigation.
Safety issues are broadly classified in terms of their level of
risk as follows:
- Critical safety issue: associated with an intolerable level of
risk and generally leading to the immediate issue of a safety
recommendation unless corrective safety action has already been
taken.
- Significant safety issue: associated with a risk level regarded
as acceptable only if it is kept as low as reasonably practicable.
The ATSB may issue a safety recommendation or a safety advisory
notice if it assesses that further safety action may be
practicable.
- Minor safety issue: associated with a broadly acceptable level
of risk, although the ATSB may sometimes issue a safety advisory
notice.
Safety action: the steps taken or proposed to
be taken by a person, organisation or agency in response to a
safety issue.
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