We understand that any accident that results in a serious injury or loss of life can have profound effects. A fatality begins a complex process of grieving for those close to the individual(s) involved. Families and friends naturally want to know why the accident happened, and how to prevent someone else having to experience such loss.
This page and accompanying brochure attempt to answer some of your questions about a transport safety investigation conducted by the Australian Transport Safety Bureau (ATSB) where there has been a fatality.
The ATSB is governed by a Commission and is entirely separate from transport regulators, policy makers and service providers.
The ATSB investigates accidents and incidents to find out what happened to prevent it from happening again. We don’t investigate to lay blame but to improve safety.
Accident investigations
The ATSB does not investigate all accidents. It focuses its limited resources on fatal and other accidents that are required to be investigated under international agreements, and also those it believes will yield the most useful safety knowledge - particularly for fare-paying passenger operations.
ATSB staff may seek to interview anyone directly or indirectly associated with a transport safety occurrence. As part of its investigation, the ATSB may need to ask some questions in order to understand crew members’ activities in the days before the accident. In this situation, you may be asked for information on your loved one’s recent rest periods, sleeping patterns, medication, general state of health, work history and other important aspects. Discussing these matters in such circumstances can be particularly difficult, so we encourage you to consider having another family member or friend available for support during the interview. ATSB staff members are trained to assist you through the interview process.
To gather relevant information, the ATSB may:
- interview any witnesses and other relevant persons
- obtain additional information relevant to the investigation from a number of different sources
- conduct tests and research, as appropriate
- analyse data recorders, such as transport vehicle voice and data recorders/loggers (the ‘black boxes’) and air traffic control tapes and other media.
During the report writing stage, a draft report is prepared for comment by persons and organisations directly involved in the accident. A person in possession of a draft report is not permitted to copy or disclose the contents of a draft report except for the purpose of providing comments to the ATSB on the draft, or to take safety action in response to the report’s findings. The ATSB carefully considers any comments by persons who have received a report prior to finalising its investigation.
As next of kin, you are generally not provided with a draft report for the purpose of commenting to assist with finalising the investigation, unless you have specialist technical knowledge, or are directly involved in the circumstances and issues that contributed to the accident. You will, however, receive a ‘for information’ copy of that draft.
Normally, you can expect a preliminary report within 30 days of a significant accident, and regular interim reports or web updates (usually every 6 months) until the final investigation report is completed. By their nature, those reports include factual information only, but will not include any analysis of the facts to date. You can also expect that there may be a number of short web updates during the course of an ATSB investigation. While the ATSB understands that this can be frustrating for relatives, it could be harmful to make conclusions before establishing all of the facts.
A copy of the final report will normally be available to you and your immediate family a number of days before its public release.
Other investigations
It may be that you feel the investigation and report have not met your expectations. The following organisations, however, may undertake a separate investigation. The intent and/or processes of these investigations will differ to the ATSB’s:
- Coronial Inquest or Inquiry. Your state or territory Coroner may hold an inquest or inquiry into a fatal transport accident, and the coronial and ATSB investigations are complementary. All queries relating to an inquest or inquiry, or to any police investigation carried out for the Coroner, should be directed to your Coroner’s Office. Coronial services can also offer face-to-face assistance and advice, and most Coronial jurisdictions provide grief counselling and other support by trained professionals. A list of those and other relevant support services is enclosed. Regulatory investigation The relevant transport regulatory authority, such as the Civil Aviation Safety Authority (CASA), Australian Maritime Safety Authority (AMSA), the Office of the National Rail Safety Regulator (ONRSR), Workcover or the police may conduct investigations to determine whether there was a breach of any legislation.
Investigation reports
ATSB transport safety investigation reports do not include the names of individuals. In many situations, however, an individual’s position (for example, the ‘pilot in command’, ship’s master, locomotive driver) may need to be stated so that the reports make sense and lessons can be learned by others. The ATSB provides copies of final investigation reports to the public and the reports are made available on our website.
Your contact with the ATSB
While the ATSB is very conscious of your loss and privacy at this very delicate time, we seek to keep you informed as the investigation proceeds. Early in the process, the investigator in charge will seek your input to plan regular communications. That communication can be with yourself or, if you would prefer, through an intermediary nominated by you. Please check that the ATSB has accurate, up-to-date contact details of your or your preferred point of contact. In addition, you can contact the investigator in charge using the information at the back of this brochure.
An integral part of the communications planning is for the investigator in charge to advise you of the pending release of any transport safety report. As well, you can expect to be offered a brief by the investigator in charge at that time, the aim of which is to explain the investigation and findings, and to attempt to answer any questions you may have. If you agree to a briefing, you should be aware that it can become very emotional, and you might consider having a friend available for support.
The investigator in charge will advise an appropriate contact number. However, if you do not have or have lost that number, you can call 1800 020 616 during business hours and ask for an investigation update. If you would rather use email, please address your correspondence to atsbinfo@atsb.gov.au.
State Coronial Counselling Services
The Coronial counselling service in your state can provide support and information to families affected by the death of a loved one that is under investigation by a coroner.