Jump to Content

Report on performance

4. Outcome 2 - Transport

Output 2.1.1 - Transport safety investigations

Highlights

In 2008-09, the Australian Transport Safety Bureau (ATSB) assessed more than 15,000 occurrence notifications and completed 79 aviation, 10 marine and 10 rail accident investigations. As a result of this work, the ATSB facilitated 185 voluntary safety actions by stakeholders across all transport modes and issued 26 safety recommendations and 10 safety advisory notices.

The high-profile events investigated by the ATSB included:

  • two events involving Qantas aircraft - a temporary loss of control on an Airbus A330 in flight over Western Australia, and a gas cylinder explosion which ruptured the fuselage and caused depressurisation on a Boeing 747 in flight near the Philippines;
  • a maritime incident involving the loss of containers overboard, which resulted in a major oil spill from the Pacific Adventurer off the coast of southern Queensland; and
  • level crossing collisions at Rungoo (north of Ingham) and Mundoo (near Innisfail), in Queensland - both accidents involved a heavy road vehicle colliding with a passenger train and both resulted in fatalities.

These investigations involved a significant initial response and required extensive national and international collaboration.

Representatives from the ATSB led the Australian delegation to the eighth International Civil Aviation Organization (ICAO) Accident Investigation and Prevention Divisional Meeting - the first such meeting in 10 years. Australia had a major influence on the outcomes of the meeting and further enhanced its reputation through submission of a number of papers and active participation during debate.

Through the Indonesia Transport Safety Assistance Package, the ATSB continued to help develop local capacity and underpin the development of a genuine safety culture in the Indonesian transport sector. This included assistance with accident investigation, and training of Indonesian transport investigators in Canberra.

On 2 December 2008, as part of the release of the Aviation Green Paper, the Australian Government announced that the ATSB would become a separate statutory agency on 1 July 2009. This move to enhance the bureau's independence received strong industry support. The ATSB worked with the Department to ensure that staffing, business systems and governance arrangements were in place to ensure a seamless transition.

Overview

Output 2.1.1 was delivered by the Australian Transport Safety Bureau (ATSB). The 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 travelling within Australia and overseas.

In accordance with the Transport Safety Investigation Act 2003, 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 also produces high-quality research reports promoting safety within the aviation industry.

The ATSB became an independent statutory agency on 1 July 2009 and will have a separate annual report in 2009-10.

The output had no administered programs.

Summary of performance

Table 4.1 summarises the Department's results in delivering Output 2.1.1, against the key performance indicators and targets published in the 2008-09 PBS.

Table 4.1 Summary of performance - Output 2.1.1

Key performance indicator Target Result
Outputs

Proportion of accident and incident notifications and confidential reports received, assessed, classified and recorded (ATSB expects to receive around 12,000 potential accident and incident notifications and around 100 confidential reports in 2008-09)

100 per cent.

The ATSB was notified of approximately 15,000 aviation, marine and rail safety accidents and incidents. Following assessment, 7,837 were classified as transport safety matters and entered into the ATSB's safety databases. The ATSB also received 133 confidential reports.

Number of selective investigations of accidents and incidents based on safety priorities and guidelines

Approximately 100 new investigations commenced.

Approximately 100 investigations completed.

The ATSB initiated 64 aviation, 11 marine and 10 rail investigations, and completed 79 aviation, 10 marine and 10 rail investigation reports.

Number of selective aviation research and analysis investigations based on safety priorities and trends

Approximately 10 new investigations commenced.

Approximately 10 investigations completed.

The ATSB commenced work on six research and analysis investigations, basing them on safety priorities and trends. Ten aviation safety research and analysis reports were released.

Major accident investigation response capabilities are developed, reviewed and tested

Each mode to participate in at least one major accident simulation either externally or ATSB-led.

The ATSB participated in six major accident response exercises, including three aviation exercises and two rail exercises. Members of the marine investigation team participated in other modal exercises.

Safety action taken by stakeholders in response to:

  • all identified safety issues; and
  • identified critical and significant safety issues, including those for which formal safety recommendations have been made

Proactive implementation of safety action by stakeholders in the majority of relevant cases reducing the need to issue formal safety recommendations.

Implementation of safety action by stakeholders in a large proportion of relevant cases.

Aviation safety stakeholders proactively undertook 132 safety actions and the ATSB issued three safety recommendations and three safety advisory notices.

Marine safety stakeholders proactively undertook 35 safety actions and the ATSB issued 10 safety recommendations and seven safety advisory notices.

Rail safety stakeholders proactively undertook 18 safety actions and the ATSB issued 13 safety recommendations.

Contribution to international working groups and major conferences

Participate in ICAO Accident Investigation Group (AIG) workshop, and present at forums of Marine Accident Investigators International Forum (MAIIF), International Society of Air Safety Investigators (ISASI) and International Transport Safety Association (ITSA).

ATSB staff members attended or presented at 79 events, ranging from presentations to university students to lectures at international conferences and symposiums. This included the ICAO AIG workshop, and the forums of the MAIIF, ISASI, Australian and New Zealand Societies of Air Safety Investigators, and the ITSA.

Compliance with international safety investigation obligations as assessed by the ICAO and IMO compliance audit regime based on the Australian legal and governance framework

Maintain 100 per cent compliant status.

The ATSB was audited under the Universal Safety Oversight Audit Program in 2008, as part of a state safety oversight audit. Two findings were made in relation to ATSB responsibilities under ICAO Annex 13 'Aircraft Accident and Incident Investigation'. One finding remains extant and is subject to a current difference notified against the relevant standard; the second finding will be addressed by 31 December 2009. The ATSB achieved 100 per cent compliance with the Voluntary International Maritime Organization Member State Audit Scheme.

Completion of endorsed ATSB projects under ITSAP for 2008-09

100 per cent completion.

The ATSB completed 95 per cent of projects that had been planned for completion. Two projects were not completed because the Indonesian National Transportation Safety Committee was unable to commit necessary resources. A number of projects are ongoing.

Detailed report on performance

The following report is against the headings from the applicable output from the 2008-09 PBS. Please note that for this output, the section 'IV Other activities' has been added to address the announcement on 2 December 2008 by the Minister for Infrastructure, Transport, Regional Development and Local Government of the transition of the ATSB to a separate statutory agency.

I    'No blame' safety investigation and research

The purpose of all ATSB investigations and research is to prevent the occurrence of accidents and incidents, rather than to apportion blame or provide a means for determining liability.

Notification, assessment and data management

In 2008-09, the ATSB assessed more than 15,000 occurrence notifications, of which 7,837 met the definition of a 'transport safety matter' and were consequently entered into modal safety databases. These comprised 7,681 aviation occurrences, 94 maritime occurrences and 62 rail occurrences.

Selective investigation

The ATSB investigates selectively, as do many equivalent international organisations. The aim is to concentrate resources on the in-depth investigations considered most likely to enhance transport safety. As many types of accidents are repetitive, investigating all accidents in detail is not 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 2008-09, the ATSB initiated 64 aviation investigations, 11 marine investigations and 10 rail investigations. It completed 79 aviation, 10 marine and 10 rail investigation reports.

Aviation safety research and analysis

In 2008-09, the ATSB continued to analyse information held in its aviation safety accident and incident database as part of Australia's obligations to the International Civil Aviation Organization (ICAO) in determining whether or not preventative safety measures are needed. The ATSB engaged industry experts and stakeholders to ensure that the research was focused, timely and relevant.

The 10 aviation safety research and analysis reports released in 2008-09 covered a diverse range of topics. They included reviews of accident and incident trends, runway excursion accidents around the world and preventative and corrective risk controls for runway excursions; a survey of the owners and builders of amateur-built and experimental aircraft; and educational reports on human factors in aircraft maintenance, and staying safe during an in-flight depressurisation. Aviation safety research publications are available on the ATSB's website.

Major accident preparedness

The 2008-09 review and testing of the response capabilities of ATSB staff complemented previous testing of ATSB operational readiness. The ATSB's 2008-09 major accident response program included exercises in both the aviation and rail modes. The aviation reviews included a desktop exercise, a progress meeting simulation, and participation in the multiagency exercise 'Graphite' at Sydney Airport. The rail team took part in the desktop exercise 'Barton', which was run by the South Australia Police, and a review of a freight train derailment in Western Australia.

II    Safety actions by stakeholders

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. The reports of the ATSB's investigations are available on its website.

In 2008-09:

  • aviation safety stakeholders proactively undertook 132 safety actions relating to safety issues identified during investigations, leading to strong gains in safety culture and practices. The ATSB released three safety recommendations and three safety advisory notices, arising from 46 investigations;
  • marine safety stakeholders proactively undertook 35 safety actions relating to safety issues identified during investigations, leading to strong gains in safety culture and practices. The ATSB released 10 safety recommendations and three safety advisory notices, arising from 10 investigations; and
  • rail safety stakeholders proactively undertook 18 safety actions relating to safety issues identified during investigations, leading to strong gains in safety culture and practices. The ATSB released 13 safety recommendations, arising from seven investigations.

III    International engagement

The ATSB has undertaken a significant level of cooperation with its regional counterparts over many years, assisting with investigations, conducting flight recorder replay and analysis, and conducting training workshops. This international engagement is extremely important to ensure that Australian citizens and travellers to and from Australia are afforded a high level of safety.

International organisations

The ATSB continued to liaise and collaborate with overseas organisations on international investigations. In 2008-09, this included providing an accredited representative to the French BEA (Bureau d'EnquĂȘtes et d'Analyses) for an investigation involving an Australian-manufactured aero-engine. The bureau also collaborated with the Philippines and the United States on the investigation of an accident involving a Qantas Boeing 747, and with France on the investigation of an accident involving a Qantas Airbus A330.

The ATSB participated in the annual meeting of Directors General of Civil Aviation, Asia-Pacific Regions, held in Kuala Lumpur, Malaysia, in November 2008.

Representation at meetings of safety investigation organisations from around the world provided opportunities for the ATSB to share insights on best practice and solutions to emerging challenges in the field of no-blame safety investigation during 2008-09. These included meetings of the Marine Accident Investigators' International Forum, International Society of Air Safety Investigators, Australian and New Zealand Societies of Air Safety Investigators, and the International Transport Safety Association.

In October 2008, more than 200 safety experts, including delegates from 75 contracting states and 12 international organisations, met at ICAO headquarters in Montreal for the eighth ICAO Accident Investigation and Prevention (AIG) Divisional Meeting. The Australian delegation, which consisted of representatives from the ATSB, the Civil Aviation Safety Authority (CASA) and Australia's representative on the ICAO Air Navigation Commission, was led by the Executive Director of the ATSB.

The meeting was the first of its kind in 10 years. Attention centred on Annex 13 to the Chicago Convention on International Civil Aviation, which establishes international Standards and Recommended Practices for aircraft accident and incident investigation. The Australian delegation had a significant input, and many of the Australian proposals were accepted.

Australia also participated in the ICAO Regional Office Cooperative Development of Operational Safety and Continuing Airworthiness Programme, a significant program of review, assessment and assistance to regional states seeking to comply with ICAO Standards and Recommended Practices.

Regional engagement

The Indonesia Transport Safety Assistance Package continued to help develop local capacity and underpin the development of a genuine safety culture in the Indonesian transport sector. In 2008-09 the ATSB provided assistance to Indonesia with at least three significant aviation and marine accident investigations. In addition, the ATSB assisted with several flight recorder replay and analysis tasks. The ATSB also provided training to Indonesian transport investigators in Canberra, with investigators from all three transport modes engaged in the 12-month Transport Safety Investigation Diploma course.

The ATSB's regional cooperation and engagement also included participation in the delivery of training courses and safety seminars in Hong Kong, Malaysia, Pakistan and Singapore.

IV    Other activities

On 2 December 2008, as part of the release of the Aviation Green Paper, the Minister for Infrastructure, Transport, Regional Development and Local Government announced that the ATSB would become a separate statutory agency, with a commission structure, on 1 July 2009.

This move to enhance the ATSB's independence received strong industry support. It will ensure that the ATSB continues to conduct the most thorough investigations possible, and to foster appropriate safety action. It will also enhance the quality of the bureau's relationship with industry and the aviation community.

In the months leading to the change of administrative arrangements, the ATSB worked with the Department to ensure that staffing, business systems and governance arrangements were in place to ensure a seamless transition.

Prev. | Index | Next