Resilient and data-driven

One such example was the reopening of our investigation of the fuel planning event, weather-related event and ditching involving Westwind 1124A, VH‑NGA, which occurred near Norfolk Island Airport, on 18 November 2009.

The main focus of the reopened investigation – one of our largest investigations ever completed – was to address all of the relevant points raised by the Senate Inquiry in the interest of completing a robust and comprehensive safety investigation. While the Aviation Safety Regulation Review in 2014 considered the ATSB’s original report on the Norfolk Island accident an aberration, and not typical of the high standard that the ATSB usually attains, we ensured that the specific findings of a peer review by the Transport Safety Board (TSB) of Canada were fully taken into account.

Prior to the reopened investigation commencing, the TSB’s review was quite favourable of the ATSB’s investigation methodology, after comparing ours against their own policies and guidance, and the standards and recommended practices, including those outlined in Annex 13 to the International Civil Aviation Organization (ICAO) Convention on International Civil Aviation. They found our methodology met or exceeded the intent and spirit of those prescribed.

One of the positive attributes in Australian aviation is the passionate expression of opinion. I have experienced this in spades during our search for MH370, and also through feedback following the publication of our investigation reports – the vast majority of which is constructive and positive. Australian Aviation recently ran a five part series focussing on the original Norfolk Island accident investigation and I was disappointed that these articles missed the opportunity to share the results of the reopened investigation and accurately reflect the current status of transport safety in Australia.

I would encourage those who have not yet done so to read the final report – in its entirety – into the reopened investigation. The investigation team reviewed evidence obtained during the original investigation and acquired a substantial amount of additional information that was not obtained or available to the original investigation team. You can download the 530-page report from our website by searching AO-2009-072.

As with all of the ATSB’s investigations, the findings of this report should not be read as apportioning blame or liability to any particular organisation or individual. We do not investigate for the purpose of taking administrative, regulatory or criminal action. Often referred to as the ‘no-blame’ approach, this does not equate with ‘no responsibility’. It simply means that disciplinary action and criminal or liability assessment are not part of an ATSB safety investigation and should, if necessary, be progressed through separate parallel processes.

‘The findings should not be read as apportioning blame.’ Greg Hood

Our Transport Safety Investigators identified and published 36 safety factors from this reopened investigation, which provide valuable lessons to flight crews, operators, regulators and other organisations, particularly operators and pilots who fly to remote islands and other isolated aerodromes. Not only here in Australia, but also around the world, to help prevent an accident like this occurring in the future.

The ATSB and the entire Australian aviation industry have come a long way since this accident occurred almost a decade ago. The ATSB has certainly learned a lot from the accident and we have fully embraced these learnings in the way in which we investigate and report today.

We are, and always have been, an independent Commonwealth Government statutory agency, entirely separate from transport regulators, policy makers and service providers. Our relationship with the Civil Aviation Safety Authority (CASA) is an appropriate relationship – respectful of our different roles in the aviation safety framework. We take our role as the national transport safety investigator very seriously and we would never compromise our independent status. CASA is treated no differently than any other directly involved party during the course of an investigation.
Every year we receive approximately 17,000 serious incident and accident notifications across the aviation, marine and rail modes – that is an average of 46 per day. We simply cannot investigate everything, and nor do we need too. We have been seeking to improve our efficiency by becoming more data-driven. We have one of the richest national information datasets of safety-related occurrences in aviation. By actively interrogating this data, we are able to more selectively allocate our resources to investigating those accidents and incidents that have the greatest potential for improving transport safety.

Consistent with our Minister’s Statement of Expectations, our primary focus is on enhancing safety with respect to the travelling public, and in particular, those occurrences that may present a significant threat to public safety and are the subject of widespread public interest. If there is no obvious public safety benefit to investigating an accident, we are less likely to conduct a complex, resource-intensive investigation. Also, there are diminished safety benefits from investigating occurrences where there are obvious contributing factors, such as an accident involving high energy, low-level aerobatics. As a result of this strategy, we commenced 127 investigations during the 2017-18 financial year across the three modes of transport, compared to 162 investigations in the previous period.

We are currently completing complex investigations in an average timeframe of 16 months. While this exceeds our 12-month target, it is commensurate or better than a number of our international counterparts. We have a program of work in place to improve our timeliness.
As is indicated on our website, all completion dates for investigations are ‘anticipated’. Transport safety investigations are complex and dynamic. The completion of an investigation can be delayed due to a range of reasons, including being influenced by factors outside of the ATSB’s control. For example, the examination and analysis phase of an investigation requires reviewing complex data and available evidence, which can sometimes be vague, incomplete and or contradictory. This may prompt the collection of more evidence, which in turn needs to be analysed and examined, and can potentially add to the length of an investigation.

We do not wait for the completion of an investigation before amplifying our safety messages. If a critical or significant safety issue is identified during the course of the investigation, we notify the relevant parties so appropriate safety action can be taken.

A recent example was the issuing of a safety advisory notice (SAN) following the collision with water of EC135, VH-ZGA, near Port Hedland on 14 March 2018. Within weeks of this accident, we identified the importance of frequent helicopter underwater escape training (HUET) for aircrew and regular passengers to increase survivability of an in-water accident or ditching. We immediately contacted all helicopter operators conducting regular overwater operations informing them of the SAN. Anecdotally, we have been informed by HUET providers of a noticeable increase in enquiries and bookings for this essential training.

We are very aware of the impact a delay to an investigation can have on directly involved parties, including next-of-kin. While the outcomes of an investigation might bring closure to these parties, our goal is always to improve transport safety. Directly involved parties are important to investigations as they form a part of the natural justice process. We do our very best to keep them and other involved parties informed on the progress throughout the course of an investigation. Any delay to an anticipated release of a report is regrettable and I acknowledge that this can generate frustration and uncertainty. However, it is very important that we conduct a thorough and meticulous investigation.

To help improve our timeliness, the Australian Government’s recent budget measures have allowed the ATSB to enter this financial year with renewed financial sustainability. This has enabled us to recruit and train an additional 17 transport safety investigators. Our new cohort of recruits are currently progressing through their training, which will take about 18 months to complete. Some have already deployed to accident sites and are making a positive impact in improving transport safety by applying their existing and newly learnt skills.

As with most organisations, the ATSB functions within an operational structure. An investigation is carried out by a team of investigators led by an investigator in charge, who reports to an investigation manager. Before a final investigation report is published, it goes through a quality assurance process to ensure an appropriate level of rigour has been applied. I review all reports before sending them to our three Commissioners for their review. As you can see, investigations are a real team effort.

The ATSB of today is a contemporary, resilient, data-driven agency intent on improving transport safety for the travelling public. The future of the ATSB will certainly have its challenges as we embrace the further rise in use of Remotely Piloted Aerial Systems, fully autonomous trains and other driverless modes of transport.

We are only a small agency, with around 110 staff. However, each and every one of us is dedicated, focused and committed to improving transport safety. We have a depth and breadth of skills at the ATSB including pilots, engineers, materials failure experts, physicists, human factors specialist, ship’s captains, train drivers, rail engineers, air traffic controllers, cabin safety specialists and a broad range of specialists across our corporate services.

In the course of their investigation activities, our investigators are required to be ready to deploy at any time of the day or night, 365 days of the year, in any weather conditions, to any serious indent or accident anywhere in Australia, and sometimes in Indonesia or Papua New Guinea.
At accident sites, our investigators sift through the wreckage to look for contributing factors. They must gather all available evidence, interview witnesses, collect CCTV and other camera footage, obtain crew and maintenance records, recover data from cockpit voice recorders, flight data recorders, smart phones, tablets, GPS units or any other electronic devices which may be useful for analysis. Investigators are also are required to deal with the police, disaster victim identification teams, landowners, witnesses and directly involved parties.

The team at the ATSB are truly the most remarkable workforce that I have had the privilege to lead, and I look forward to ensuring the reputation of the ATSB remains as one of the most respected transport safety investigation agencies in the world.