‘We have to get it right’: Inside the ATSB

Ultimately, we’re here to influence safety and uncover systemic issues that may exist – not just what happened in a particular incident but how it could affect other operations. An accident investigation isn’t just undertaken to look at what has occurred. It also looks at what we can improve and what recommendations we can make. How can we help influence safety for everyone in future operations?

AA: A key principle of your investigations is the no-blame approach. Can you elaborate on that?

AM: It’s not necessarily well understood. It’s around what we gather, and we have some very strong powers available to get the evidence, and that’s important. But equally, we need the trust of those working with us so that people report accidents, knowing that what they give us will not be used in a criminal or civil setting. So that’s where the no blame bit comes in, and the data and evidence we get are highly protected.

Of course, we put out very transparent reports on every investigation. We look at the sequence of events and our hypothesis model is the same for every inquiry. We look at individuals, what happened, the outcome, and the individual actions, particularly around equipment and people with a safety role. Then we look at the environment that they operated in, and does that tell us any contributing elements?

Then we go above the line, which is where our skill set comes in. What are the organisational influences? What was the safety management system? Was it sufficient? Was it followed? Were there deficiencies there? What was the regulatory environment? What was the manufacturing environment? They’re the sorts of things that our skill set comes to bear because that’s where systemic improvements can be made. So we do focus on the systemic, but equally, we go through a sequence of events of what’s occurred so people can understand. What are the recommendations we’ve made? And most importantly, how can we influence safety going forward? But that no blame is the core premise around how we operate.

AA: Your reports are incredibly detailed and can take years to complete. What is the scope and scale of a serious investigation?

AM: They go into so much detail for several reasons. So, there are various phases of our investigation. One of them is collecting all the evidence at the beginning.

Evidence collection can last many weeks, and that’s from what we find at a site, but also all of the paperwork, maintenance logs, regulatory framework and experience of those involved. All of that takes time.

We like to get a thorough basis of our evidence before we even start to think about why and what went wrong. Then, we begin to test several hypotheses. We don’t simply come up with a theory and then fit the evidence to it. We will run several hypotheses and then test them on the evidence that we’ve got. We often work with the owners if we identify a safety issue, whether the owner is an operator, the regulator, or a manufacturer. At the end of the report, it’s a good news story: we found this and this is what’s been done to reduce risk in the future. That’s the benefit of having a transparent, independent investigator.

But equally, we’re very mindful that there are a lot of consequences that come from our reports. So, our reports impact individuals, companies, and share prices. We have to get it right. There isn’t a Court of Review that sits above our reports. We have to make sure that our recommendations are firmly rooted in the evidence and that we can demonstrate that the evidence has got us there, not the feeling, not the experience of our investigators putting their own bias on top of things.

It’s very much evidence-based, and that does take some time. Still, equally, we go through that natural justice, where we try and work with those that we’ve had to investigate to make sure that it is a good news story at the end, that risk has been reduced because of what we’ve found and what’s been implemented after it.

AA: What skills do ATSB investigators need? They must understand aircraft operations, engineering, and human factors.

AM: The agency’s strength is very much in its people. Many organisations will say that, but it’s very much the case here. You need experienced personnel, and we need them across many skill sets. And when answering your last question, how many people work on investigation? Every investigation could have half a dozen because we may need operational or pilot perspectives.

We may need a LAME or an aeronautical engineer to comment on parts of the accident sequence. We may need a materials failure expert there if we’re looking at things like any materials with a contributory role. We’ll have human factors staff that work on it, too. And we’re across rail and maritime as well. The skill set is pretty broad, and specialist groups will lend that skill set to multiple investigations.

So, it’s never the role of one investigator to come up with a report. A dozen people could have some form of interaction and have provided some of their expertise to a report. Again, that’s one of those other reasons why we go to great lengths to understand the evidence and get the very best people to analyse that evidence, and that goes into every report.

AA: Aviation is undergoing significant technological changes – drones, electric aircraft, and automation. How is the ATSB preparing for this shift?

AM: Across all the transport modes, it is constantly evolving. Risk is always changing. You know, we saw a different risk profile during COVID. We’ve seen a different risk profile coming out of COVID. What is constant is human interaction in transport systems, and yes, it’s getting more complicated, whether it’s with AI or its increasing use of automation. Several things will constantly change, but what is constant within it is human interaction, and we do a lot of work on that human interaction and human elements.

But equally, we need to make sure that we’re keeping on top of where those trends are going, and we see that through all the data we get. And that’s one of the beauties of the ATSB: data comes to us raw. We then examine where trends are occurring, whether we have those skill sets moving forward, and what will likely be risked tomorrow, next week, or next year. They’re very much at the forefront of our minds because they’re the ones that we need to start influencing safe cultures in organisations to match whatever the changing environment is going to be.