Waypoint 2007

Investigation and data issues

Kym Bills
Executive Director ATSB
30 August 2007

 Multi-modal
ATSB

 ATSB
I was privileged to establish the ATSB on 1
July 1999 and to help build its international
and national reputation in aviation and
marine investigation, road safety, and
increasingly rail investigation
Process review and cultural change takes
time and since 2003 we have had solid
legislation in place (currently being fine-
tuned) and a nationally accredited diploma
in transport safety investigation
115 staff across 4 modes, most in aviation.

Australian transport safety data
As in other OECD countries, most fatalities
are on roads - crashes cost A$18b pa

 ATSB
Transport safety investigations are not
intended to be the means to apportion
blame or liability, in accordance with the
Transport Safety Investigation Act 2003 and
Annex 13 to the Chicago Convention
Powers to investigate, including to compel
evidence even if incriminatory and
reports/evidence cant be used in courts
ATSB is part of DOTARS for administration
and funding but separate from State bodies
like Police and rail regulators, and federal
bodies like the CASA & Airservices.

SAFETY SYSTEM
Importantly, separate investigations by
police, regulators and OHS bodies occur
consistent with a just culture (perhaps 10%
of accidents include culpable actions)
The ATSBs no-blame safety investigation
is only one part of the total safety system
ATSB mandatory occurrence reporting and
voluntary confidential reporting, with data
analysis and research, supplements both
investigation & industry schemes (eg SMS).

Aviation safety data
Fatal LCRPT accidents in 2000 (Whyalla)
& 2005 (Lockhart River) but most
accidents/fatals GA & trending as below:

Aviation safety data
We continue to see many of the same
types of fatal accident, eg:
- controlled flight into terrain
- weather (eg VFR into IFR conditions)
- fuel exhaustion/starvation
- hitting powerlines
- high risk GA behaviour (eg low passes)
Human factors continue to dominate -
management lack of awareness of human
performance limitations remains an issue.

Aviation safety data
The ATSBs Australian Aviation Safety in
Review covers 749 accidents 2001-2005
(mostly non-fatal; 2005 last data re hours)
197 mechanical: 101 powerplant, 86
airframe, 10 aircraft systems accidents
552 operational/handling: 197 collision
type, 105 aircraft control, 74 hard landing,
34 wheels up, 32 fuel related accidents
In terms of phase of flight, 49% approach
and landing; 21% take-off and initial climb.

Safety data and investigation
May 2004 $6.3m Budget funding for a new
Safety Investigation Information Management
System (SIIMS) over 4 years
On time and under budget, we expect SIIMS
to streamline electronic reporting
Also re-coding of historical data to enable
research comparison and trend analysis
Expect increase in incident reporting to
continue (c 8000 last FY) via safety culture
Choice of 80 investigations pa increasingly
difficult, of which 30 are more detailed.

ATSB business context aviation SIIMS

ATSB investigation
ATSB 500 page Lockhart River final
report released on 4 April 2007 & refined
our prior methodology & used SIIMS
ATSB also conducted a research study
into instrument approaches
Considered all aspects of the aviation
system which included organisational &
regulatory issues as well as aircraft/crew
The ATSB methodology does not require
findings against each layer if not found to
be significant.

ATSB investigation analysis

 Safety Investigation
200501977

Collision with Terrain

11 km NW Lockhart River Aerodrome
7 May 2005, RPT 2 crew/13 pax fatalities
VH-TFU, SA227-DC (Metro)

Lockhart River approach profile

South Pap

Accident site

Safety factors and safety issues
ATSB investigations encourage safety
action ahead of the final report with release
of recommendations if necessary
Safety factors are events or conditions that
increase safety risk
Safety issues are safety factors that have
the potential to adversely affect the safety
of future operations and are not just based
on a specific individuals behaviour they
are safety deficiencies requiring action.

Contributing safety factors
Defined as a safety factor that, if it hadnt
occurred/existed the accident would
probably not have occurred or another
contributing safety factor would probably
not have occurred or existed
Probably/likely >66% cf civil law test >50%
Evidence not sufficient for some (eg CRM)
hence these are other safety factors
Diagram shows 19 contributing safety
factors (black border) and 13 of the 21
other safety factors (purple outline).

Theaccimapdiagramisbuiltfromthebottomup
Issues and challenges
Using all available means to avoid a major
accident is a primary challenge
This includes good safety management
systems (SMS) among all key players
Understanding of the limits to human
performance and organisational behaviour
Risk analysis, threat & error management
Helped by excellence in regulation, ATS ...
Learning from others, mindfulness of past
lessons

Issues and challenges
Striking the right balance between protecting
safety data and legal systems
Getting the balance right between no-blame
and culpability in a just culture
Trade-off between investigation timeliness
and thoroughness (eg with media and
societal expectations - instant gratification)
The growing safety/security interface
Using tools/data like LOSA, FOQA etc and
perhaps increasing commercial expertise
Reinforcing appropriate independence.

Conclusion
Australia has a very safe transport system in
international terms across all sectors
However, major accidents are low probability,
high consequence events and we can never
afford to be complacent
Systemic investigations remain crucial but pro-
active reporting and data analysis also provide
for evidence-based risk reduction
The ATSB will continue to work cooperatively
with stakeholders to advance safety while
maintaining necessary investigative
independence.

 Thank you

Questions?