ATSB

This review suggested that while BASI had strong capabilities and a great reputation, it could be even better and also had much to offer in the way of technical expertise which was helpful for investigations in other modes of transport.

Subsequently, the ATSB was formed in July 1999 by the merging of transport accident units covering aviation, rail and marine accidents, as well as road accident data gathering.

Kym Bills, who had headed the maritime division within the Department of Transport since 1994, was appointed the Executive Director of the new bureau and has held the position ever since.

Bills said that the formation of the ATSB was a watershed for transport safety in Australia.

“We actively sought to create an Australian body which was equal to the best practice of other bodies around the world, including the US National Transport Safety Board and the Canadian Transportation Safety Board. ” The ATSB’s sole objective is simply ‘safe transport’. It aims to promote this by investigating and reporting on transport accidents and other safety occurrences, collecting data on transport safety and encouraging safety action to improve future transport safety.

Under a number of international conventions and Australian law, the ATSB’s investigations do not seek to apportion any blame or fault and cannot be used in criminal prosecutions or civil disputes; however, they are often referred to in coronial inquests.

The ATSB operates under the Transport Safety Investigation Act of 2003. This legislation was drafted in consultation with industry over a few years and equips the bureau with the appropriate powers relating to investigations and safeguarding evidence and enables it to continue its work of safety investigation.

While the focus of the TSI Act is no-blame and future safety, the Act also enables reporting of certain acts to the Australian Federal Police and the Commonwealth Department of Public Prosecutions. This may include incidences where accidents have not been reported, false statements made to the bureau, or where evidence has been tampered with.

This helps to maintain the integrity of the bureau’s investigative process, resulting in a safer outcome for all.

To conduct these investigations, the bureau has a staff of over 100 people, many of whom have come from technical backgrounds, including pilots, ships’ captains, engineers and metallurgists. “We’re lucky in that many staff have come to the ATSB as a second or third career to give something back to their industries,” said Bills.

To ensure that the bureau’s capabilities are maintained, the agency has a strong focus on developing the skills of its investigators. “We

“We’re lucky in that many staff have come to the ATSB as a second or third career to give something back to their industries.”

”also do a fair bit of training and mentoring in house, as well as using experts from around the world,” said Bills.

All investigators undergo training under the bureau’s nationally accredited Diploma of Transport Safety Investigation. This includes a well recognised course in human factors, which runs twice a year. While it is primarily a course for ATSB staff, the bureau also has limited places for other interested parties, and these places are often in high demand.

While the ATSB receives its greatest public exposure from aviation accident investigations, it is also tasked with investigating interstate rail and maritime accidents and incidents involving large vessels.

With its maritime accident investigations, the bureau works closely with industry and the Australian Maritime Safety Authority. In recent years, this has included the investigation into the grounding of the Pasha Bulker cargo ship off the coast of Newcastle, among others.

The bureau has also been asked to assist with investigations overseas. In recent times, this has included the investigation into QF1 at Bangkok, the Singapore Airlines 747 which took off from the wrong runway in Taipei, and the crash of a Garuda Boeing 737 at Yogyakarta in March last year.

Most often, the ATSB is involved in assisting with the analysis of flight data recorders and cockpit voice recorders.

According to Bills, this has mostly been conducted on behalf of New Zealand and Indonesian authorities.

The ATSB’s international involvement has stepped up this year, with the bureau receiving funding to assist the Indonesian National Transportation Safety Committee to improve its investigative resources. This is part of a greater cooperation on air transport safety which Transport Minister Anthony Albanese recently agreed with his Indonesian counterpart. Aside from its accident investigation role, the ATSB is also tasked with maintaining the national database of aviation safety incidents and accidents and undertaking research into any identifiable trends from these. This is driven by the obligations under Chapter 8 of Annex 13 to the international Chicago Convention.

For a few years, the ATSB also administered small grants for research into aviation safety issues. Kerryn Macaulay, the director of strategy and capability, said that these were administered at a time when the bureau did not have sufficient capability to carry out all of the research in-house. “We didn’t have a critical mass of staff to be able to meet our obligations for conducting research activities each year,” she said.

Over time, the ATSB has acquired this expertise and now conducts most of this work in-house. “We’re resourced to take on up to 10 projects a year, so it’s a small but significant part of our overall role,” said Macaulay.

Air Accident Investigations

Air accident investigation is one of the major tasks of the ATSB, and this accounts for a large amount of the bureau’s resources.

All investigations start with the reporting of an accident or incident. Under the Transport Safety Investigation Regulations, the owner or operator of an aircraft or other responsible person must report serious occurrences to the bureau as soon as practical, and most come through the bureau’s toll free reporting phone number.

Not all occurrences reported are investigated.

Julian Walsh, director of aviation safety investigation, said that last year the ATSB received 14,000 notifications, of which 8000 were assessed by the bureau as incidents and accidents. From these assessed reports, the bureau is resourced to investigate about 80 aviation accidents and incidents each year.

The bureau prioritises the investigations based on a number of criteria. The first is whether an international carrier is involved in an accident which must be investigated under the Chicago Convention. Secondly, ATSB policy is to investigate only non-sport fatal accidents. The bureau also considers the likely outcome of the investigation, as well as the level of public interest and how likely it is to contribute to increasing air safety, before it launches the investigation. The size and composition of the investigation team will vary depending on the complexity of the investigation.

Generally, fatal accidents will involve on-site investigations by between two and five investigators, under the direction of an investigator in charge.

While a large amount of data and physical evidence is gathered at the crash scene, the investigation usually involves a large range of sources for its data collection, including maintenance documentation, weather data, witness accounts, ATC recordings, cockpit and flight data recordings, regulatory documentation, and pilot training and medical records.

After assessing the data, the ATSB normally releases a preliminary factual report within 30 days of the accident, and may release interim factual report(s) prior to the release of the final report.

Preliminary and interim factual reports usually outline the sequence of events leading up to a crash and some of the conditions when it took place. The bureau may also give advice as to what the focus of the ongoing investigation activities will be.

Naturally, the process moves into analysing the available data. At this stage, the analysis runs through an extensive review process.

“This includes a formal peer review process, a number of management reviews which run through the team leader and involves me and the executive director, and a directly involved party draft report review process,” said Walsh.

During the analysis, the bureau may issue safety recommendations if it believes that there is value in issuing them immediately rather than waiting for the production of a final report. Other recommendations may be listed in the final report. The ATSB will then follow up on these (left) The ATSB is tasked with maintaining a database of aviation incidents and accidents and researching any identifiable trends from these. (right) Executive Director Kim Bills. (ATSB) recommendations and report their outcomes on its website and in its annual review. The ATSB prefers to encourage safety action ahead of its final report which means that many recommendations are often adopted ahead of the final report.

The biggest investigation undertaken by the bureau recently has been the investigation into the 2005 crash of the Transair Metroliner while on approach to the Aboriginal community at Lockhart River in Queensland. Thecrash resulted in the loss of 15 lives and stands as one of the worst air disasters in Australia’s history.

“Given that this was the worst civil aviation accident since 1968 the scale of our initial response and the resources we committed to the investigation were significant,” said Walsh.

The first phase involved an on-site team of 10 investigators working either at the crash site at Lockhart River, in Cairns or in Brisbane. The team consisted of ATPL pilots, LAMEs, aerospaceengineers and human factors specialists. Added to this there was a great deal of administrative and other support from the office back in Canberra through the life of the investigation.

Walsh explained that the on-scene crash investigation was made challenging due to the terrain at the site. “Our investigators had to be helicoptered in as the area was only accessible by winch. ” Aside from the crash scene, other data was collected from sources including the Bureau of Meteorology, Transair and other Metro operators, CASA, and a number of other bodies and individuals.

In all, the bureau conducted over 100 interviews and also sorted through 25,000 pages of documentation as well as some data from the aircraft’s flight data recorder and other sources.

In addition to the accident investigation, the bureau also undertook a research study into ‘Perceived Pilot Workload and Perceived Safety of RNAV (GNSS) Approaches’. This complemented the Lockhart final investigation report,with a number of the issues identified being relevant to issues of chart presentation and workload that the investigation identified as safety factors.

In the final 500 page investigation report on the accident, which was released on April 4 2007, the bureau identified 19 contributing safety factors.

It is important to note that the bureau did not say that any one of these contributing safety factors on its own would have led to the accident. The bureau’s definition of a contributing safety factor includes one that, if it had not occurred or existed at the relevant time, then another contributing safety factor would probably not have occurred or existed.

The majority of the contributing safety factors in the report fell into this part of the ATSB definition. Ten of the contributing safety factors related to the actions of the crew on the day, while a further seven related to Transair’s operational procedures and organisational structure.

The remaining two related to CASA’s oversight of Transair’s operator management systems, and to risk assessments when evaluating applications for the initial issue or subsequent variation of an Air Operator’s Certificate. At the time these were released, CASA reacted strongly to the suggestion that it contributed to the accident, with CEO Bruce Byron going so far as to say that the authority was not responsible for the actions of the pilots in control of the aircraft.

Other safety factors were identified relating to the design and chart presentation of RNAV (GNSS) approaches in general, and specifically with respect to the Lockhart River runway 12 RNAV (GNSS) approach.

Overall, the investigation into the Lockhart River accident took over two years to pull together and many thousands of man-hours in data gathering, analysis and report writing. Further to its own investigation, the ASTB also assisted with a coronial inquest into the deaths of the people on board.

Atsb And Casa

As would be expected, the ATSB works closely with CASA as part of its investigation process and also to follow up on safety recommendations it has made.

The ATSB also publishes a supplement to CASA’s Flight Safety Australia magazine which often gives updates on the status of ongoing investigations and research.

As demonstrated by the Lockhart River crash, the relationship between CASA and the ATSB has at times been tense. In many cases, the ATSB has to review the relationship between CASA and the ATSB and review the actions of CASA and how they may have contributed to air accidents, putting both organisations in tension with each other.

This was highlighted in the coronial report on the crash, where the Queensland state coroner raised concern that there was a danger of the ATSB’s recommendations being ignored and a “lessthan fulsome response to some of them. ” As a result, he recommended that the federal minister for transport consider engaging an external consultant to assess whether high level intervention was warranted.

The minister at the time, Mark Vaile, agreed with this recommendation and appointed Russel Miller, a lawyer from Minter Ellison who had extensive aviation experience, to lead the review.

The report was completed in December last year and released in March by current Minister Albanese for public comment. While overall it was positive about the relationship between the two agencies, the report also suggested 19 recommendations to improve it.

Public comment on the report is now open until April 30.

Some of these recommendations were largely administrative in nature, while others related to changes to legislation.

One of the recommendations of the Miller report was that CASA and the ATSB should work together to coordinate their safety research efforts.

“This would help to build a healthy working relationship between the agencies, provide a positive basis for interaction between them at all levels and likely improve the utility of the research output,” said the report.

The biggest recommendations related to the governance of the ATSB and potential provision of ATSB investigation material to CASA in cases of “serious and imminent risk”. Among the former, the review suggested that a separate commission comprised of three parttime commissioners should be established to review ATSB investigations before reports are released.

Some sections of the industry have already expressed concern over these recommendations.

There is particular concern that a commission model would compromise the independence of the ATSB, as these commissioners would be employed by the department.

There is also concern about the proposed model of information sharing due to the threat of CASA taking action to suspend a licence or AOC.

When asked about the Miller review, Kym Bills said that it would not be appropriate for him to make any comment until the industry comment period had finished and the minister has made a decision.

Despite the review and its recommendations, Bills maintains that day-to-day relations with CASA and the wider industry are still strong.

“Perhaps surprising, since the ATSB’s main investigation work takes place only when something has gone badly wrong and led to an accident or serious incident, our relationships with the industry including the regulator and service providers are generally good,” he said.

Overall, the ATSB has improved on the legacy of quality investigations and research it inherited and is confident that the lessons learned from these have helped to make transport in Australia safer. Although some changes may come from the recommendations of the Miller report, the focus of the Bureau will always remain safe transport.