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Report on performance

Transport outputs and programmes

Output 1.1.1: Transport Investigation

(Australian Transport Safety Bureau)

Effectiveness

Australia's transport safety investigation regime meets international standards

Australia's transport safety investigation regime is set out in the Transport Safety Investigation Act 2003 and accompanying regulations. The legislation empowers the Australian Transport Safety Bureau (ATSB), through its executive director, to:

  • investigate safety accidents and incidents involving civil aviation, international and interstate shipping and the defined interstate rail network
  • conduct 'no blame' investigations in which the focus is on learning to improve future safety rather than on criminal or civil liability.

ATSB Executive Director becomes Chairman of the International Transportation Safety Association

The high status of the ATSB amongst influential international transport investigation bodies was reflected in the appointment of the ATSB's Executive Director, Mr Kym Bills, as Chairman of the International Transportation Safety Association, which includes a dozen of the major independent transport safety investigation bodies from around the world. The previous chairman was the Chairman of the US National Transportation Safety Board. Mr Bills is the fourth chairman since 1993.

Response to ATSB safety recommendations from regulators and industry

In 2005-06 the ATSB released 93 final aviation reports and issued 22 aviation safety recommendations, including 18 formal recommendations and 4 safety deficiency notices. Aviation regulators and industry fully or partly accepted 11 ATSB aviation recommendations, including recommendations on two-crew qualifications for instrument approaches, onboard recording devices, and fuel probe systems on SA227 Metro aircraft. The bureau is monitoring acceptance of two recommendations on cockpit voice recorder maintenance and a further three recommendations on fitting of autopilots, terrain awareness warning systems, and a review of certain separation procedures contained in the Manual of air traffic services. One recommendation was not accepted and there was one non-response in the time expected for responses.

The ATSB's 40 marine recommendations from 13 completed investigations included those on the Malu Sara investigation, which led to significant safety actions on the part of the various parties involved in the operation and certification of the vessel (see the ATSB case study on page 40). The Lowlands Grace investigation resulted in the lifeboat equipment manufacturer undertaking a review of its equipment design.

The ATSB's 83 rail recommendations from 11 rail investigation reports plus those on the joint Queensland Transport-ATSB Tilt Train investigation and on the Benalla rail level crossing investigation for the Victorian Government have provided information to the rail industry to improve rail safety and, in particular, have led to the upgrading of health standard requirements for rail safety-critical workers.

Enhancing international effectiveness in major aviation accident investigation

The revised International Civil Aviation Organization (ICAO) Manual of aircraft accident and incident investigation is expected to be published in November 2006. The ATSB, at the invitation of ICAO, has made a substantial contribution to the drafting and editing of this publication.

Improving standards for rail and maritime investigation

Australia has made significant progress in developing standards for rail and maritime investigations including:

  • coordinating a group redrafting the International Maritime Organization (IMO) Code for the investigation of marine casualties and incidents and means of making the provisions mandatory
  • developing an Australian standard for rail investigation (albeit further improvement is required).

Quality

Stakeholders accept safety action recommended through investigation reports

Industry and regulators taking independent safety actions

Safety regulators, manufacturers and operators are encouraged to take steps to improve safety as investigations progress, and the ATSB prefers to be able to report positive safety action taken rather than making formal safety recommendations.

In 2005-06 the ATSB's aviation safety stakeholders undertook 129 separately identified safety actions linked to 45 ATSB aviation investigations in addition to actions on recommendations. These safety actions included: redesign, due to engine failures, of high pressure turbine blades; US Federal Aviation Administration action on air data inertial reference units following control problems on a Perth-Kuala Lumpur Boeing 777 flight; and, following a fuel starvation close call, CASA issued an aircraft maintenance direction on fuel indication systems, in response to which the operator introduced new fuel indication and maintenance control procedures. The ATSB also undertook 13 separate safety actions relating to these aviation investigations in addition to recommendation action.

Similar to 2004-05, this approach saw a limited number of aviation recommendations issued in 2005-06: 22 were issued (18 formal recommendations and four safety advisory notes) compared with 21 in 2004-05. Rail and marine recommendations continued at a higher level.

Aviation safety messages well accepted

In 2005-06 the ATSB instigated 84 and released 93 final aviation occurrence and technical investigation reports. That output is slightly below the 98 reports released in 2004-05 (up from 63 in 2003-04). High-profile reports released in 2005-06 included the fatal:

  • Robinson R22 helicopter accident near Camden, New South Wales
  • Piper Cheyenne accident near Benalla, Victoria
  • Piper Chieftain accident near Mount Hotham, Victoria.

The ATSB issued significant aviation safety recommendations, as outlined below:

  • Following its interim factual report into the Metroliner aircraft accident near Lockhart River in Far North Queensland, which resulted in 15 fatalities, the ATSB issued three recommendations to CASA on crew qualifications for instrument approaches, the potential safety benefit of autopilots, and maintenance requirements for cockpit voice recorders (CVRs) and flight data recorders (FDRs), and also issued a recommendation in relation to legislation covering CVR/FDR maintenance to DOTARS.
  • The bureau also issued a recommendation to CASA about installation of terrain awareness warning systems (TAWS) on turbine-powered aircraft below 5,700 kg and turbine-powered helicopters following a review of a number of Controlled Flight Into Terrain accidents in recent years, including the Piper Cheyenne accident near Benalla.

In response to these recommendations, CASA has amended the Civil Aviation Order (CAO) on instrument ratings for crew members, is reviewing the relevant CAO and international best practice on the fitment of autopilots, and is considering the various aspects in relation to the terrain awareness warning system. CASA is working with DOTARS on legislative amendments for CVR/FDR maintenance requirement changes.

Aviation safety messages continued to be well accepted, with operators, manufacturers and regulators undertaking significant safety action in cooperation with the ATSB's investigations. Significant safety action also included the Airservices Australia enhanced training for controllers, upgraded software for The Australian Advanced Air Traffic System (TAAATS) and improved instructions for controllers relating to responses to route adherence monitoring alerts following the Benalla fatal accident.

Key priorities for 2006-07 include completing and releasing the Lockhart River report and introducing the aviation investigation and project management modules of a new government-funded safety investigation IT system-the Safety Investigation Information Management System (SIIMS). SIIMS will also enhance the ATSB's ability to assess the more than 12,000 aviation event notifications received each year.

Did you know?

While most ATSB safety investigation staff are located in its Canberra central office, there are small regional offices in Brisbane, Adelaide and Perth.

The ATSB Canberra central office features laboratory facilities to support safety investigations through analysis of recorded and physical evidence. Cockpit voice and flight data recorders ('black boxes') can be examined, as can all types of materials, structures and components. The ATSB also has a developing capacity to examine voice and data recorders from other types of transport vehicles.

Quality

Stakeholders accept safety action recommended through investigation reports (continued)

Marine investigations lead to regulatory changes

In 2005-06 the ATSB completed 13 marine investigation reports. High-profile reports released include those on:

  • the loss of the Department of Immigration and Multicultural Affairs vessel, Malu Sara, in the Torres Strait, which resulted in five deaths
  • the lifeboat accident on board the bulk carrier, Lowlands Grace, while anchored off Port Hedland, Western Australia, which resulted in two deaths.

The Malu Sara investigation has led to significant safety actions on the part of the various parties involved in the operation and certification of the vessel (see the ATSB case study on page 40).

Despite the high number of collisions between fishing boats and much larger cargo vessels (24 since 1990, with two involving fatalities), the safety messages have been slow to penetrate the commercial fishing industry. Throughout 2005-06 the ATSB has continued its campaign to raise safety awareness in the fishing industry.

In 2006-07 the ATSB expects to release approximately 10 marine investigation reports, including the report into the collision between two vessels that resulted in the significant oil spill in Gladstone in January 2006. In addition, the safety awareness campaign with the Australian commercial fishing industry is expected to continue.

Table 3.2 shows the trends in transport safety investigation.

Rail safety investigation recommendations benefit stakeholders

The ATSB released 11 rail safety reports in 2005-06, together with a joint Queensland Transport/ATSB investigation report on the serious Tilt Train accident and the Benalla rail level crossing collision investigation for the Victorian Government. The ATSB reports related to six derailments, three safe working irregularities, a shunting fatality, and a collision between a train and a road/rail vehicle. Eighty-three rail safety recommendations were issued in the ATSB reports. The recommendations relate to:

  • medical standards for safety-critical workers
  • track 'fitness for purpose', inspection and maintenance
  • safe working procedures, particularly communication
  • rolling stock performance
  • loading and marshalling of wagons
  • shunting procedures.

In October 2005 the Queensland Minister for Transport and Main Roads released the final report of the joint Queensland Transport/ATSB investigation into the Tilt Train accident that occurred north of Bundaberg in November 2004. In February 2006, the Victorian Minister for Transport released the final report on the ATSB investigation into the October 2002 Benalla rail level crossing accident. The ATSB submitted the report to the Victorian Government in September 2004.

In 2006-07 the ATSB will continue the investigation of eight rail incidents which occurred in 2005-06. These include a significant investigation into an axle failure on a scheduled XPT passenger train from Sydney to Melbourne, which occurred near Harden, NSW.

Previous attempts to create a national database to obtain robust and harmonised rail safety data have not been successful, due to problems in data from different database systems and other issues. An improved national database of rail accidents and incidents is now being developed in cooperation with rail regulators in the states and the Northern Territory. Such a database would serve as a valuable resource for industry, regulators, investigators and researchers. The ATSB, on behalf of the Australian Government, has contributed $80,000 to an audit coordinated by Queensland Transport on behalf of rail regulators to seek a way forward for legacy data and robust future data.

Investigations are completed, on average, within one year

Turnaround times exceed target for aviation and rail and are well below target for marine

In 2005-06 the ATSB's median report completion time for aviation investigations was 379 days, up from 247 days last year. This result, which exceeded the target of 365 days, reflects the significant diversion of resources for training new investigators, for the development of SIIMS, for coronial inquests and for the Lockhart River investigation. There will continue to be substantial work on the Lockhart River investigation and SIIMS training in 2006-07, after which improvements in timeliness are expected. Resources required for coronial inquests are expected to be significant in 2006-07.

The median report completion time for marine investigations was 234 days, a significant improvement over the previous year's result of 372 days and well below the target of 365 days.

For rail reports under the Transport Safety Investigation Act 2003 (TSI Act), the median completion time of 479 days was well above the target of 365 days, but below the 519-day median in 2004-05. Rail report completion times are improving as investigators in our relatively new rail unit become more experienced and non-TSI Act work such as on the Tilt Train accident declines.

Table 3.2 shows the trend in transport safety investigation.

Major accident investigation response capabilities are reviewed and tested annually

High level of response readiness maintained

In 2005-06, the ATSB reviewed its structures, policies and procedures for responding to a major transport safety accident in Australia. A workshop aimed at identifying strategies for improved major accident preparedness, including training and management issues, was conducted in April 2006. ATSB staff and technical experts from the UK, including from Cranfield University and the Air Accidents Investigation Branch, participated in the workshop.

A desktop aviation accident exercise is planned for the first half of the 2006-07 financial year.

More than 5,000 aviation, maritime and rail safety accident and incident reports are assessed

In 2005-06, approximately 12,500 event reports were assessed, covering 131 accidents and 7,458 incidents in aviation, marine and rail modes-well over the 5,000 report benchmark. This reflects increased aviation reporting through Airservices Australia's electronic safety information reporting system, as well as increased reporting by the aviation industry as a result of greater familiarity with the TSI Act and regulations.

Approximately 120 fatal accidents and other serious occurrences are investigated to improve future safety

In 2005-06 we released 119 final reports (112 in 2004-05): 93 aviation reports, (98 in 2004-05); 13 marine reports, (11 in 2004-05); and 13 rail reports (3 in 2004-05).

In 2006-07 the ATSB intends to complete around 90 aviation, 10 marine and 10 rail investigations, including finalisation of the report on the fatal accident at Lockhart River.

Price

$19.2m

The actual price of this output in 2005-06 was $19.0 million.

Overall performance

Table 3.2 Trends in transport safety investigation

2002-03

2003-04

2004-05

2005-06

2006-07 Est.

Civil aviation

Accident and incident notification a

Incidents notified

5,797

4,404

5,890

7,349

Accidents notified

151

152

157

122

Total accidents and incidents notified

5,948

4,556

6,047

7,471

- b

Volume of investigations

Investigations started during year c

62

75

109

84

90

Investigations completed during year

78

63

98

93

90

Investigations continuing at 30 June

66

76

86

81

90

Timeliness of investigations

Median time to completion (days)

279

347

247

379

<365</p>

Number of ongoing investigations more than one year old at 30 June

14

15

14

18

Outcome of investigations

Recommendations issued

62

46

21

22

No set target

Maritime investigations

Accident and incident notification

Total accidents and incidents notified

Not reported

Not reported

92

79

- b

Volume of investigations

Investigations started during year

15

8

13

12

10

Investigations completed during year

13

17

11

13

10

Investigations continuing at 30 June

20

9

12

10

10

Timeliness of investigations

Median time to completion (days)

399

484

372

234

<365</p>

Number of ongoing investigations more than one year old at 30 June

6

6

3

2

-

Outcome of investigations

Recommendations issued

42

47

42

40

No set target

Safety notices issued under the Marine Confidential Reporting System

n/a

n/a

13

13

10

Rail investigations d

Accident and incident notification

Total accidents and incidents notified

n/a

Not reported

61

39

- b

Volume of investigations

Investigations started during year

4

5

7

9

10

Investigations completed during year

5

3 e

3

13 f

10

Investigations continuing at 30 June

4

6

11

8

10

Timeliness of investigations

Median time to completion (days)

- g

- g

519

479

<365</p>

Number of ongoing investigations more than one year old at 30 June

-

1

3

-

-

Outcome of investigations

Recommendations issued

23

23

22

83

No set target

Total price of output h

$11.3m

$12.5m

$17.5m

$19.0m

$19.4m

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a Fewer notifications were made in 2003-04 due to the initial impact of changed reporting requirements from 1 July 2003 under the Transport Safety Investigation Act 2003 and regulations.
b At least 6,000 aviation, maritime and rail accident and incident reports are expected to be received in 2006-07.
c While the government has provided extra funding for more investigations from 2004-05, the time required to recruit and train investigators delayed the average number of investigations completed and the median completion time for investigations.
d Until 1 July 2003, investigations were a state responsibility and the ATSB was involved only at the request of state governments. Median completion times for these investigations were not reported due to the time required for state governments to consider some reports before their release.
e This includes the Chiltern rail investigation report submitted to the Victorian Government in late 2003-04. This report was released to the public in October 2004.
f This includes the Benalla rail investigation report submitted to the Victorian Government in September 2004 and released to the public in February 2006.
g Until 1 July 2003, investigations were a state responsibility and the ATSB was involved at the request of state governments. Median completion times for these investigations are not reported due to the time required for state governments to consider reports before their release. Completion time estimates for rail investigations under the ATSB's new powers cannot be reported, as none were completed in 2003-04.
h This includes the direct cost of investigations as well as indirect costs such as DOTARS-attributed corporate overheads.

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