The primary objective of any investigation into an air
safety occurrence is the prevention of an accident
Sometimes an investigation will uncover a safety deficiency in
the aviation system and recommendations are made to address the
deficiency. At other times the details and circumstance of an
accident or incident don't immediately uncover a safety deficiency
or even provide immediate answers. However, the occurrence data is
collected and stored in the ATSB database and may at some time in
the future form part of a wider analysis of safety issues.
A safety deficiency is defined in the Transport Safety
Investigation Act 2003 subection 23(2) as one of the
categories of transport safety matters that can be investigated. It
is defined as:
Something that occurred that affected, is affecting, or
might affect, transport safety.
To identify a deficiency the ATSB first collects information
from an investigation or safety (research) study. Then it analyses
the data and works with the industry to develop safety
recommendations and actions.
Aviation safety deficiencies may be found in many factors and
could include one or more of the following:
- aircraft or component design
- the manufacturing or quality control process
- maintenance and/or engineering procedures
- regulatory standard, information and advisory documents
- operational procedures
- Air Traffic Services procedures and documentation
- corporate management procedures.
If recommendations are made as a result of a safety deficency,
they are sent to the most appropriate organisation or agency to
effect change. This may include the Civil Aviation Safety
Authority, Airservices Australia, maintenance and aircraft
operators and manufacturers.