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Report on performance

Outcome 2-Transport Outputs and Programs

Output 2.1.1-Transport safety investigations

Highlights

On 23 May 2008, the Australian Transport Safety Bureau (ATSB) released its final report into the grounding of the Panamanian-registered bulk carrier Pasha Bulker at Newcastle, New South Wales. The Pasha Bulker ran aground at Nobbys Beach on 8 June 2007, when a storm hit a group of ships that were moored offshore while waiting to load coal.

The investigation involved the collection and interpretation of a vast amount of data and in-depth research of specific issues. The ATSB surveyed the masters of ships anchored off Newcastle at the time, to gain an understanding of what information they had had, and how it had affected their decision making. The role and actions of Newcastle Port Corporation and its Vessel Traffic Information Centre were explored, including through evidence taken from the Pasha Bulker's voyage data recorder.

Other aspects that were examined included the safety issues associated with the anchorage, local weather conditions, anchor holding power, water ballast and the queue of ships waiting to load coal, as well as the logistics and processes involved in exporting coal from Newcastle.

The investigation report included 11 recommendations and four safety advisory notices. It also acknowledged the safety actions taken by Newcastle Port Corporation and Port Waratah Coal Services in response to the incident.

Overview

The Department, through the Australian Transport Safety Bureau (ATSB), works with the aviation, marine and rail industries; transport regulators; and governments at the state, national and international levels; to improve transport safety standards for all Australians.

The ATSB undertakes independent 'no blame' investigations of aviation, interstate rail and international and interstate marine accidents and incidents, seeking to uncover causal factors and encourage safety action to prevent future accidents. The ATSB performs its investigative functions in accordance with the provisions of the Transport Safety Investigation Act 2003 (TSI Act). In addition, the ATSB researches aviation safety issues and produces high-quality research reports, promoting safety within the aviation industry.

ATSB publications are available on the bureau's website www.atsb.gov.au and in hard copy upon request.

As part of a broader restructure of the Department, the ATSB Road Safety Branch moved to the Infrastructure and Surface Transport Policy business division in March 2008. The branch reports on its performance under Output 2.3.2 - Road safety and vehicle policy, programs and regulation.

Output 2.1.1 corresponds to Output 1.1.1 and Output 1.1.2 (excluding road safety and vehicle safety standard aspects) in the previous outcome and output structure (see Appendix L for a comparison between the current and previous structures). Output 2.1.1 is delivered by the ATSB.

Table 4.2 summarises the output's performance in 2007-08.

Summary of performance

Table 4.2 Summary of performance - Output 2.1.1 - Transport safety investigations

Performance indicators Results
Effectiveness

Stakeholders undertake safety action in response to critical and significant safety issues identified through safety investigations.

In 2007-08, aviation safety stakeholders undertook 131 separately identified safety actions linked to safety issues identified in 43 ATSB aviation investigations, leading to strong gains in safety culture and practices. The ATSB issued a further 22 aviation safety recommendations, which also generated several safety actions.

In surface transport safety, 42 rail safety recommendations and 32 marine safety recommendations were issued, drawn from the results and insights of various investigations. To draw attention to important safety issues, the ATSB issued 39 marine safety advisory notices, seven rail safety advisory notices and two aviation safety advisory notices.

Transport safety and public confidence in transport safety is maintained or improved.

In April 2008, the ATSB published the Railway Level Crossing Safety Bulletin. The bulletin had a positive impact on transport safety and public confidence by identifying significant issues relating to level-crossing safety. Feedback from users of the bulletin was very positive.

In 2007-08, ATSB staff members attended or presented at 97 events, ranging from presentations to high school students to lectures at international conferences and symposia. The ATSB also provided information via its website, publishing investigation reports and additional safety material.

ATSB aviation, marine and rail reports and recommendations were well accepted by regulators, operators and other safety stakeholders.

The ATSB also provides citizens with the opportunity to share their concerns about transport safety through confidential reporting schemes. In 2007-08, the ATSB received 104 reports through REPCON, the aviation confidential reporting scheme; six reports, through the Confidential Marine Reporting Scheme (CMRS); and seven reports through the Aviation Self Reporting Scheme (ASRS).

Quality

Australia's transport safety investigation regime meets international standards.

The principles of relevant international agreements are embodied within the provisions of the Transport Safety Investigation Act 2003 and given force through section 17, so that Australia legally complies with international agreements.

In February 2008, the International Civil Aviation Organization (ICAO) Universal Safety Oversight Program audited Australia's aviation safety oversight and service provision. The final report of the audit is yet to be received, although the results are expected to recognise the ATSB as a best-practice agency in a range of investigation activities.

Investigations are completed, on average, within one year.

The median completion time for ATSB investigation reports in 2007-08 was 442 days, comprising 443 days (358 in 2006-07) for aviation, 319 days (320 in 2006-07) for marine and 456.5 days (369 in 2006-07) for rail reports.

The completion of several aviation reports was delayed due to the diversion of staff resources to provide input to coronial inquests and other staffing constraints. The increase in rail report median completion time was due to the completion of a number of older investigations.

Staff required to appear as witnesses at coronial hearings are well prepared.

In 2007-08, ATSB aviation staff gave evidence at five coronial hearings, and assisted the Queensland State Coroner with the ongoing inquest into the disappearance of the Malu Sara in the Torres Strait in October 2005. The ATSB ensures that all staff who provide evidence at inquests are experts in the fields under consideration and are thoroughly conversant with the briefs. In their findings, coroners have generally noted their heavy reliance on ATSB reports and the value of evidence provided by ATSB investigators.

Seven staff members attended the ATSB course Coronial Witness Training.

Major accident investigation response capabilities are reviewed and tested annually.

The ATSB participated in four exercises designed to assess response capabilities in the event of a major accident. This included two 'desktop' discussion exercises and two major accident simulations at airports.

The benefits of the new Safety Investigation Information Management System 'SIIMS', commissioned for aviation investigations in April 2007, are extended to rail and marine.

IT development work and staff training were completed on the ATSB's newly commissioned Safety Investigation Information Management Systems (SIIMS), enabling extension of its benefits to marine and rail investigations. All marine and rail investigations commenced on or after 1 January 2008 use SIIMS as the primary investigation management and analysis tool.

Statistical analyses and conclusions are accurate and robust.

The ATSB validated its data sources with alternative sources wherever possible, and the statistical content of all research was critically reviewed to ensure it was accurate, methodologically sound and correctly interpreted.

In implementing SIIMS, the ATSB reviewed safety occurrence records, helping to ensure that reliable information will be available to the public.

Aviation safety research reports are timely and informative.

Research findings were widely reported in Australia and overseas, and reports were commented on favourably by stakeholders in government and industry. Aviation research reports were released in time to influence or assist ATSB investigations of aviation occurrences and contribute to public understanding of aviation safety.

Quantity

More than 6,000 aviation, marine and rail safety accident and incident reports are assessed and entered into the safety database.

The ATSB's notification staff assessed 8,423 aviation, marine and rail safety accident and incident reports, and entered these reports into ATSB's safety databases.

Approximately 100 fatal accidents and other serious occurrences are investigated to improve future safety.

The ATSB initiated 98 investigations in 2007-08, comprising 77 aviation, 11 marine and 10 rail investigations. The ATSB released 97 final accident and incident investigation reports in 2007-08, comprising 73 aviation, 12 marine and 12 rail reports.

Fewer aviation reports were released than planned, due to the diversion of staff resources to provide input to coronial inquests and other staffing constraints.

Appropriate assistance is provided with major international investigations upon request.

Under the Indonesia Transport Safety Assistance Package (ITSAP), the ATSB assisted the Indonesian National Transportation Safety Committee with several aviation investigations. These included investigations of the fatal accidents that occurred at Yogyakarta Airport in March 2007 and the Makassar Strait in January 2007.

The ATSB also provided technical assistance to New Zealand for the recovery of flight recorder data after an attempted hijacking in February 2008.

10 aviation and 25 road safety statistical and research publications are released.

The ATSB released and published on its website 11 aviation safety research and analysis reports.

The ATSB Road Safety Research and Statistics Branch moved to the Infrastructure and Surface Transport Policy Division in March 2008. For reports on its performance, see Output 2.3.2.

Price

$23.8 million

The actual price of this output in 2007-08 was $23.8 million.

Overall performance Mostly achieved.

A cockpit voice recorder that was retrieved from the ocean floor is being prepared for shipment by an ATSB investigator

A cockpit voice recorder that was retrieved from the ocean floor is being prepared for shipment by an ATSB investigator (Photo DITRDLG)

Detailed report on performance

Effectiveness - Output 2.1.1

Stakeholders undertake safety action in response to critical and significant safety issues identified through safety investigations.

 

Safety actions

Rather than releasing formal recommendations in a transport safety investigation, the ATSB prefers to encourage the relevant stakeholders to initiate safety action. However, depending on the level of risk associated with a safety issue and the extent of corrective action undertaken by the relevant organisation, a recommendation may be made either during or at the end of an investigation.

Aviation

In 2007-08, the ATSB released 73 aviation safety investigation final reports. The ATSB released 22 safety recommendations and two safety advisory notices, arising from seven investigations. Aviation safety stakeholders undertook 131 separate safety actions relating to safety issues identified in 43 aviation safety investigation reports. The reports on those investigations are available on the ATSB website.

In one notable example, as a result of an ATSB investigation into an in-flight engine malfunction in a Boeing 737 on a scheduled passenger flight from Brisbane to Sydney in August 2005, the engine manufacturer undertook the following corrective actions:

  • redesigned the high-pressure compressor (HPC) anti-rotation pin;
  • released an alert service bulletin to all operators and maintainers of CFM56-3 engines worldwide that recommended the introduction of the new pin design into existing engines; and
  • made amendments to the CFM56-3 maintenance manual for HPC stator shroud component inspections.

Did you know

Beacons
In Australia, most flight data recorders are fitted with battery-operated underwater locator beacons (ULB). The beacon is activated when immersed in water and will operate for a minimum of one month. They have been known, however, to operate for more than six months (depending on the state of the battery). A ULB can withstand depths of up to 6,000 metres and can typically be detected from a distance of around 3,000 metres. In the event that an aircraft with flight recorders crashes in water, the ATSB should be able to locate the flight data recorder and the cockpit voice recorder using a ULB detector.

Stakeholders undertake safety action in response to critical and significant safety issues identified through safety investigations (continued).

 

 

Significant worldwide safety actions were taken following an ATSB investigation into the onset of severe vibrations from the main rotor system of a Robinson R22 II Beta helicopter that was being operated on an instructional flight.

  • The helicopter manufacturer published a series of safety alerts, service letters and safety bulletins, recommending the regular inspection of the blades for evidence of skin disbanding and the refinishing of blades showing abrasion of the leading edge.
  • Airworthiness directives from the Australian Civil Aviation Safety Authority (CASA) and the United States of America Federal Aviation Administration (FAA) mandated inspections of the R22 and R44 main rotor blades.
  • A third party aerospace company was issued FAA approval for the installation of protective rotor blade tape to the leading edges of R22 and R44 main rotor blades.
  • The United States of America National Transportation Safety Board issued a number of safety recommendations to the FAA, including that the FAA:
    - require the Robinson Helicopter Corporation to develop non-destructive inspection techniques to detect bonding defects; and
    - review the manufacturing processes and continued airworthiness requirements for blades manufactured by companies other than the Robinson Helicopter Corporation.

In both of these cases, the implementation of the comprehensive safety actions taken by the various parties will significantly reduce the likelihood of future accidents.

Marine

In 2007-08, the ATSB released 12 marine safety investigation reports, which included 32 safety recommendations and 39 safety advisory notices to stakeholders.

The ATSB's final report into the grounding of the bulk carrier Pasha Bulker at Newcastle, New South Wales, in June 2007, included a total of 15 recommendations and safety advisory notices. They were aimed at reducing the risk of a similar incident and improving other aspects of maritime safety, including specific issues at the port of Newcastle.

In response to the incident and the ATSB draft report, the port authority and the coal terminal operator took a number of safety actions. Newcastle Ports Corporation is now more closely monitoring ships using the Newcastle anchorage, providing them with additional advice and information about the anchorage, and has enhanced its weather broadcasting service. Port Waratah Coal Services has also enhanced the information provided to ship's masters using Newcastle and is conducting ongoing discussions, including on safety issues, with ships' agents, owners and operators. Further actions to address the recommendations in the final report are under consideration.

In its report into the breakaway and grounding of the bulk carrier Creciente at Port Hedland, Western Australia, in September 2006, the ATSB issued a number of recommendations and safety advisory notices to reduce the risks posed by mooring-related incidents. These types of incidents can result in the blockage of the port's main shipping channel. The port authority took safety action in the form of a local marine notice to address mooring-related issues.

Rail

In 2007-08, the ATSB released 42 rail safety recommendations and seven safety advisory notices in 12 final reports and one supplementary rail investigation report.

The ATSB report on the major level-crossing collision near Ban Ban Springs, Northern Territory, in December 2006, recommended that relevant authorities consider identified issues in relation to:

  • the medical examination of heavy vehicle drivers;
  • sighting distance requirements at level crossings used by high combined gross mass vehicles;
  • driver compliance at railway level crossings; and
  • accident response in the light of the remoteness of much of the Northern Territory rail corridor.

The Northern Territory Government undertook a number of actions in response to the ATSB report, including imposing increased penalties for road user noncompliance at level crossings and providing further public education regarding level-crossing safety.

Transport safety and public confidence in transport safety is maintained or improved.

Public awareness activities

In 2007-08, ATSB staff members took part in 97 events ranging from presentations for high school students to lectures at international conferences and symposiums. These included:

  • a speech at the Aviation Law Association of Australia and New Zealand Twenty-seventh Annual Conference;
  • a lecture to students at the Australian Defence Force Academy;
  • a presentation on accident investigation techniques to students of Bremer State High School in Ipswich, Queensland;
  • presentations on aspects of marine casualty investigation at conferences, including Pacific 2008, the biannual conference of the National Marine Safety Committee and the Marine Accident Investigators' International Forum; and
  • training activities and workshops related to maritime law and pilotage.

By maintaining a public profile at industry events and educating stakeholders on prominent issues, the ATSB maintained and improved public confidence in transport safety.

The ATSB also promoted transport safety by publishing safety material on its website.

Aviation safety

In aviation safety, the ATSB initiated 77 investigations and released 73 final reports in 2007-08. There were 92 ongoing investigations at 30 June 2008.

The ATSB improved safety and public confidence in aviation through its Australian investigations and its work to assist Indonesian investigations. Australian aviation topics that attracted particular public interest included the final reports on:

  • the in-flight break-up of a Piper PA31-350 Chieftain near Condobolin, New South Wales, in December 2005;
  • the engine failure and forced landing of a Cessna Caravan aircraft onto Lake Burbury, Tasmania, in February 2006;
  • the crash of a Cessna 206 near Willowbank, Queensland, in January 2006; and
  • the in-flight break-up of a British Aircraft Corporation 167 Strikemaster near Bathurst, New South Wales, in October 2006.

Marine safety

In marine safety, the ATSB initiated 11 investigations and issued 12 investigation reports in 2007-08. At 30 June 2008, there were 10 ongoing investigations.

ATSB marine investigations and their findings both inform and educate various maritime industry participants. An important example in 2007-08 was the final investigation report into the grounding of the bulk carrier Pasha Bulker at Newcastle, New South Wales, in June 2007. This comprehensive report identifies a number of key safety issues to reduce the risk of similar incidents occurring in the future.

Another significant example was the report on the breakaway from the wharf and subsequent grounding of the bulk carrier Creciente in Port Hedland, Western Australia, in September 2006. The report highlighted the risks associated with the failure of a ship's mooring system, and the potential for such incidents to result in the blocking of the port's main shipping channel.

The ATSB's marine investigation work also included the analysis of a variety of casualty investigation reports from other countries, under the auspices of the International Maritime Organisation (IMO), and cooperation with Indonesian authorities to improve maritime transport safety in their country. Other work this year included assisting the Queensland State Coroner's inquest into the disappearance of the Malu Sara in the Torres Strait in October 2005.

Rail safety

In rail safety, the ATSB initiated 10 investigations and issued 12 final investigation reports, one supplementary report and a safety bulletin in 2007-08. Ten investigations were ongoing at 30 June 2008.

ATSB rail safety investigations and recommendations, and the resulting safety actions, improve public confidence. The bureau's role as an independent, 'no blame' safety investigator for the defined interstate rail network is recognised and accepted in Australia.

Significant reports released included the final report on the major level-crossing collision near Ban Ban Springs, Northern Territory, in December 2006, and a number of other reports on level-crossing collisions, such as a fatal accident near Wingeel, Victoria, in November 2006 and an accident that seriously injured a truck driver near Virginia, South Australia, in December 2007.

In the supplementary report on the Ban Ban Springs collision, the ATSB issued a safety advisory notice to state and territory road transport authorities and rail regulators about sighting distances at level crossings controlled by 'Stop' signs and used by high combined gross mass road vehicles.

In April 2008, the ATSB published the Railway Level Crossing Safety Bulletin. The bulletin identified significant issues relating to level-crossing safety. The ATSB received very positive feedback from users of the bulletin, including requests to reproduce extracts from the bulletin in other publications, particularly magazines targeting the trucking industry.

The Victorian Minister for Public Transport requested ATSB assistance in investigating a collision that occurred between a passenger train and a B-double truck at a level crossing at Kerang, Victoria, in June 2007. Although the accident did not occur within the ATSB's agreed jurisdiction, ATSB investigators assisted the Victorian Office of the Chief Investigator with aspects of the investigation, including human performance, the accident site survey, animation of the accident sequence, and assessment of the compliance of the level crossing with the relevant Australian Standard for signage and sighting.

Confidential reporting

The ATSB provides citizens with the opportunity to share their concerns regarding transport safety via confidential reporting schemes. In 2007-08, 104 reports were made through REPCON, the aviation confidential reporting scheme; six reports were made through the Confidential Marine Reporting Scheme; and seven reports were made through the Aviation Self Reporting Scheme.

Quality - Output 2.1.1

Australia's transport safety investigation regime meets international standards.

 

 

 

 

 

Legislative framework

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

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

The principles of relevant international agreements are embodied within the provisions of the TSI Act and given force through section 17 so that Australia complies with the international agreements.

Audit of safety oversight and service provision

A comprehensive audit pursuant to the ICAO Universal Safety Oversight Program was conducted in February 2008. The audit focused on all Australian agencies with a responsibility for aviation safety oversight and service provision - the Department (including the ATSB), Airservices Australia, the Bureau of Meteorology, CASA and the Australian Maritime Safety Authority's search and rescue function, AUSSAR. The final report of the audit is yet to be received, although the results are expected to recognise the ATSB as a best-practice agency in a range of investigation activities.

Benchmarking of safety investigation programs

The ATSB is participating in a benchmarking exercise, which commenced in March 2008 and is expected to be finalised in 2008-09, with the Transportation Safety Board of Canada and the United States National Transportation Safety Board. The exercise aims to identify best practices in the delivery of safety investigation programs and services by comparing organisations in terms of:

  • safety investigations for all modes;
  • technical facilities, including engineering laboratories;
  • safety research;
  • report production;
  • communications;
  • statistics and macro analysis; and
  • support of and involvement with international working groups.

Introduction of new code for marine safety investigations

The Code of the International Standards and Recommended Practices for a Marine Safety Investigation into a Marine Casualty or Marine Incident was adopted by the IMO on 16 May 2008, and is expected to come into effect on 1 January 2010. The ATSB played a major role in initiating the development of the code and in drafting its provisions.

When the code comes into effect as a part of the International Convention for the Safety of Life at Sea (SOLAS), it will represent a major advance in international maritime safety investigation. Australia, as a signatory to the SOLAS Convention, will be required to conduct safety investigations into very serious marine casualties (deaths, loss of ship or severe damage to the environment) involving any Australian ships. The code also provides for the investigation of marine casualties in Australian waters.

Meetings with safety investigation organisations

Representation at meetings of safety investigation organisations from around the world provided opportunities for the ATSB to share insights on best practice and seek solutions to emerging challenges in the field of no-blame safety investigation during 2007-08.

The International Society of Air Safety Investigators meeting was held in Singapore in August 2007. ATSB investigators were particularly interested in presentations on challenges that arise when conducting joint investigations with foreign agencies, such as the difficulties experienced in collating information in a foreign language or cultural differences in the approach to accident investigation. A presentation by the FAA focused on relatively low-cost, very light jets that are entering service in private operations in the United States.

The Marine Accident Investigators' International Forum meeting was held in China in October 2007. The ATSB's representative gave a presentation on the investigation into the grounding of the Pasha Bulker. The presentation included details of the data collection techniques employed to identify the safety risks present and the survey of the practices by the crews of other ships that were in the area at the time of the grounding. Separately, a correspondence group was established, led by Vanuatu, to collect further data on issues surrounding 'enclosed spaces' incidents with a view to providing a paper on the findings to the IMO. The ATSB participated in this correspondence group.

The annual International Transportation Safety Association meeting was held in Russia in May 2008. Of particular note was a presentation on the investigation conducted by the United Kingdom Marine Accident Investigation Board into the break-up of the MSC Napoli in rough weather. The techniques used to establish the break-up mechanism and sequence, based on advanced simulation software, set a benchmark for other investigation authorities to follow.

Investigations are completed, on average, within one year.

In 2007-08, the ATSB's median time to complete reports for aviation investigations was 443 days, up from 358 days in 2006-07. This increase was the result of various factors, including the diversion of resources to provide input to coronial inquests; provision of investigator and technical support to Indonesia; staff turnover and associated recruitment/training; ongoing training and familiarisation in the use of SIIMS; and the completion of a number of older investigations.

The median report completion time for marine investigations was 319 days, down slightly from 320 days in 2006-07. At 30 June 2008, two of the 10 ongoing marine investigations were more than 12 months old.

For rail reports under the TSI Act, the median completion time of 456.5 days was up from 369 days in 2006-07. This reflects the completion of a number of older investigations. At 30 June 2008, all but one of the 10 ongoing rail investigations were less than a year old.

Staff required to appear as witnesses at coronial hearings are well prepared.

Preparing for and attending coronial inquests involved considerable ATSB resources in 2007-08.

In 2007-08, ATSB aviation staff gave evidence at five coronial inquests, including the inquest into the aviation accident at Lockhart River, Queensland, that was discussed in detail in the 2006-07 annual report. The findings of the five inquests were, in the main, consistent with the ATSB investigation findings.

ATSB marine investigators continued to assist the Queensland State Coroner with the inquest into the disappearance of the Malu Sara in the Torres Strait in October 2005. Hearings were conducted on Thursday Island over five weeks during 2007-08. The coroner was expected to hand down his findings towards the end of 2008.

In order to equip its staff for the responsibility of appearing as expert witnesses at coronial hearings, every year the ATSB conducts a course, Coronial Witness Training, which combines theory and several hours of scenario-based exercises. In 2007-08, seven staff members attended the course.

Major accident investigation response capabilities are reviewed and tested annually.

The 2007-08 review and testing of the response capabilities of ATSB staff complemented previous testing of ATSB operational readiness.

The ATSB's 2007-08 major accident response program included a desktop discussion exercise that considered recovery aspects of a major accident, conducted in association with primary response agencies at Sydney Airport in May 2008.

In December 2007, ATSB staff travelled to Port Macquarie, New South Wales, to participate in Exercise: Rock My Baby - a large desktop exercise that contemplated interagency responses to an aviation accident at Lord Howe Island, which has fewer resources than ports in mainland Australia.

The ATSB also participated in on-site and central office response and recovery exercises for a major aviation accident simulation, held at Lord Howe Island in May 2008 and at Gold Coast Airport in June 2008. This program is ongoing, with simulations to be conducted at the Perth and Sydney airports in 2008-09.

These collaborative exercises have led to an internal review of the ATSB's Major Accident Response Guidelines, aimed at simplifying and streamlining the ATSB's response to a major accident. The review is expected to be completed in early 2009.

The benefits of the new Safety Investigation Information Management System 'SIIMS', commissioned for aviation investigations in April 2007, are extended to rail and marine.

Development work and staff training were completed on the ATSB's newly commissioned Safety Investigation Information Management Systems (SIIMS), enabling extension of its benefits to marine and rail investigations. All marine and rail investigations commenced on or after 1 January 2008 use SIIMS as the primary investigation management and analysis tool.

Additional work continued on a range of other SIIMS enhancements intended to improve the rigour of the investigation process, provide more transparent management oversight and facilitate ease of reporting. This enhancement work included:

  • migration of recoded legacy data into the new modal occurrence databases to allow for easier and more accurate reporting;
  • introduction of the investigation report workflow management tool to improve the efficiency and visibility of the report review and release process; and
  • integration between SIIMS and the ATSB's public website to facilitate a more efficient and timely process for posting investigation-related information on the website, including a self-service facility to permit public access to basic aviation occurrence statistics.

Statistical analyses and conclusions are accurate and robust.

 

Review of occurrence records

Since the implementation of SIIMS in 2007, the ATSB has commenced a review of all occurrence records. The review will continue for the next 12 to 18 months, checking data quality and integrity. This process will ensure that future publicly released information is of a higher and more reliable standard.

Aviation safety

The ATSB's aviation safety research and analysis section undertook statistical analyses using a variety of data sources, such as the ATSB's aviation safety accident and incident database. As part of the ATSB's internal review process, data sources were validated and the analysis was reviewed to ensure that the results were accurate, methodologically sound and correctly interpreted.

In December 2007, the ATSB published an aviation research and analysis report that examined trends in immediately reportable matters (as defined in the TSI Act) involving regular public transport operations. This report informed the aviation community of important safety trends, and provided the travelling public with a better appreciation of the types of occurrences that are reported to the ATSB.

Rail safety

To assist in maintaining and continuously improving rail safety, each state and territory government has implemented rail safety legislation and established a rail safety regulator. As part of a process of sharing responsibility for rail safety, industry reports rail safety occurrences to the regulator. The regulators and operators use the resulting data to assist with their safety analyses and programs.

In May 2008, the ATSB published Australian rail safety occurrence data covering the period from 1 January 2001 to 31 December 2007. This type of data is collected from state and territory rail regulators and published on a jurisdictional basis. It covers eight categories: fatal and serious injuries; running line derailments; running line collisions; level-crossing occurrences; signals passed at danger; loading irregularities; track and civil infrastructure irregularities; and rail industry activity. The published data is available on the ATSB website.

Aviation safety research reports are timely and informative.

In 2007-08, the ATSB continued to analyse information held in its aviation safety accident and incident database to determine whether preventive safety measures are needed as part of Australia's obligations to ICAO. The ATSB engaged industry experts and stakeholders to ensure that the research was focused, timely and relevant.

The 11 aviation safety research and analysis reports released in 2007-08 looked at a diverse range of subjects covering incident and accident trends, investigation methodology, passenger health, and engineering. They included:

  • an analysis of Australian birdstrike occurrences between 2002 and 2006;
  • a review of the literature on the risk of disease transmission within an aircraft cabin;
  • an overview of the use of fibre composite in aircraft;
  • a discussion paper on the ATSB investigation analysis framework; and
  • a study on the reliability of reciprocating engines.

The ATSB published a study that provided an overview of 'controlled flight into terrain' (CFIT) occurrences, from an international perspective; explored the initiatives introduced in an effort to reduce CFIT; and specifically identified the characteristics associated with CFIT in Australia. A summation of the report findings was presented at the Flight Safety Foundation's Approach and Landing Accident Reduction Tool Kit Workshop Series in May 2008.

Aviation safety research publications were made available on the ATSB website.

Quantity - Output 2.1.1

More than 6,000 aviation, marine and rail safety accident and incident reports assessed.

In 2007-08, the ATSB assessed more than 15,400 occurrence notifications (up from approximately 13,400 in 2006-07), of which 8,423 met the definition of a 'transport safety matter' and were consequently entered into modal safety databases. These comprised 8,299 aviation occurrences, 67 maritime occurrences and 57 rail occurrences. The 8,423 occurrences comprised 208 accidents and 8,215 incidents. (For the definitions of accidents and incidents, consult the glossary on page 426).

The overall increase was almost exclusively attributable to an increase in aviation reporting, considered to be the result of an increase in aviation activity and greater familiarity with the reporting requirements contained in the Transport Safety Investigation Regulations 2003.

Due to jurisdictional differences in marine and rail reporting, the number of accidents and incidents reported to the ATSB is a subset of all accidents and incidents. The remainder are reported to, and fall within the jurisdiction of, agencies of the relevant states and the Northern Territory.

Approximately 100 fatal accidents and other serious occurrences are investigated to improve future safety.

The ATSB investigates selectively, as do many equivalent international organisations. The aim is to concentrate resources on in-depth investigations considered most likely to enhance transport safety. As many accidents are repetitive, investigating all accidents in detail may not be justified, given the ATSB's limited resources. In such cases, the ATSB will not necessarily attend the scene, conduct an in-depth investigation or produce an extensive report.

In 2007-08 the ATSB initiated 98 investigations:

  • 77 aviation safety (89 in 2006-07);
  • 11 marine safety (15 in 2006-07); and
  • 10 rail safety (13 in 2006-07).

In 2007-08 the ATSB released 97 final investigation reports (down slightly from 103 in 2006-07), comprising:

  • 73 aviation safety (80 in 2006-07);
  • 12 marine safety (14 in 2006-07); and
  • 12 rail safety (9 in 2006-07).

Fewer aviation reports were released than planned, due to the diversion of resources to provide input to coronial inquests; provision of investigator and technical support to Indonesia; staff turnover and associated recruitment/training; and ongoing training and familiarisation in the use of SIIMS.

Appropriate assistance is provided with major international investigations upon request.

 

Assistance to Indonesia

The Indonesia Transport Safety Assistance Package (ITSAP) is intended to develop local capacity and underpin the development of a genuine safety culture in the Indonesian transport sector. It is administered as a single whole-of-government program with the Department leading the program and other portfolio agencies delivering the assistance through technical transfer of skills from aviation and maritime safety specialists.

In May 2008 an Indonesian investigator completed the ATSB's 12-month diploma-level training as an aviation safety investigator. The project was jointly funded by the ATSB and an AusAID Fellowship.

The ATSB also conducted training courses in Indonesia - for example, courses on human factors and basic investigation. These courses are designed to provide the knowledge base for conducting and reporting investigations according to ICAO standards.

The ATSB expanded its program of capacity-building assistance to Indonesia during 2007-08, providing new opportunities for international aviation and marine investigators. The ATSB will offer an expanded diploma program for Indonesian marine and aviation investigators in 2008-09.

The ATSB cooperated with its Indonesian counterpart, the National Transportation Safety Committee (NTSC), in the investigation of two fatal accidents involving Boeing 737s, at Yogyakarta Airport in March 2007 and at the Makassar Strait in January 2007. This involvement was undertaken at the invitation of the Government of Indonesia and conducted in accordance with international standards. It included on-site investigation, flight data and cockpit voice recorder replay and analysis and report writing.

The ATSB also provided assistance for other high-profile aviation investigations and for marine investigation analysis.

Assistance to New Zealand

The ATSB assisted the New Zealand Civil Aviation Authority with its investigation of the attempted highjacking of a passenger flight from Blenheim to Christchurch, New Zealand, in February 2008. The ATSB is the only government organisation in the South East Asian region with the necessary facilities to download flight data recorders and cockpit voice recorders. The ATSB recovered the audio record of the incident and provided it to the New Zealand Civil Aviation Authority.

10 aviation safety statistical and research publications are released.

The ATSB released and published on its website 11 aviation safety research and analysis reports. They comprised nine in-house research reports and two external research reports commissioned by the ATSB.

Table 4.3 Trends in transport safety investigation

  2004-05 2005-06 2006-07 2007-08
Civil aviation
Accident and incident notification
Incidents notified 5,810 7,435 7,720 8,125
Accidents notified 157 124 112 174
Total accidents and incidents notified 5,967 7,559 7,832 8,299
Volume of investigations
Investigations started during year 109 84 89 77
Investigations completeda 98 93 80 73
Investigations continuing at 30 June 86 81 87 91
Timeliness of investigations
Median time to completion (days) 247 379 358 443
Number of ongoing investigations more than one year old at 30 June 14 18 9 22
Outcome of investigations
Recommendations issued 21 22 19 22
Safety reports received under the REPCON Aviation Confidential Reporting System n/a n/a 62 104
Safety notices issued under the REPCON Aviation Confidential Reporting System n/a n/a 25 86
Maritime investigations
Accident and incident notification
Total accidents and incidents notified 92 79 117 68
Volume of investigations
Investigations started during year 13 12 15 11
Investigations completed 11 13 14 12
Investigations continuing at 30 June 12 10 11 10
Timeliness of investigations
Median time to completion (days) 372 234 320 319
Number of ongoing investigations more than one year old at 30 June 3 2 1 2
Outcome of investigations
Recommendations issued 42 40 38 32
Safety notices issued under the Marine Confidential Reporting System 13 13 8 5
Rail investigations
Accident and incident notification
Total accidents and incidents notified 61 39 46 57
Volume of investigations
Investigations started during year 7 9 13 10
Investigations completed 3 13b 9 12
Investigations continuing at 30 June 11 8 12 10
Timeliness of investigations
Median time to completion (days) 519 479 369 456.5
Number of ongoing investigations more than one year old at 30 June 3 - 2 1
Outcome of investigations
Recommendations issued 22 83 39 42
Total price of outputc $17.5m $19.0m $19.3m $23.8m

a 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.
b This includes the Benalla steam train rail investigation report submitted to the Victorian Government in September 2004 and released to the public in February 2006.
c This includes the direct cost of investigations as well as indirect costs such as Infrastructure-attributed corporate overheads.

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