The ATSB recommends that QR review their SPAD investigations and
related Employee Management System procedures with focus on the
following:
- Ensuring that a system of investigation and counselling for
relevant safetycritical staff exists, which adheres to strict
timelines, to ensure SPAD incidents are fully dealt with in the
timeliest manner. - Investigation of SPADs includes examination of individual
actions and organisational factors so that all causal factors are
identified. - Review the monitoring and management of employees who have
returned to safety-critical tasks after involvement in a SPAD,
particularly multi-SPAD or high-category SPAD employees.