The ATSB receives around 15,000 notifications of aviation
occurrences each year, 8,000 of which are accidents, serious
incidents and incidents. It is from the information provided in
these notifications that the ATSB makes a decision on whether or
not to investigate. While some further information is sought in
some cases to assist in making those decisions, resource
constraints dictate that a significant amount of professional
judgement needs to be exercised.
There are times when more detailed information about the
circumstances of the occurrence would have allowed the ATSB to make
a more informed decision both about whether to investigate at all
and, if so, what necessary resources were required (investigation
level). In addition, further publically available information on
accidents and serious incidents would increase safety awareness in
the industry and enable improved research activities and analysis
of safety trends, leading to more targeted safety
education.
To address the risks posed by having to make decisions, on
whether to conduct an investigation, within a short time frame
based on preliminary information only, the Chief Commissioner has
decided to gather additional factual information on all aviation
accidents and serious incidents (with the remaining exception of
'high risk operations¹),
where the initial decision has been not
to commence a 'full' (level 1 to 4) investigation.
To enable this, the Chief Commissioner has established a
small team to manage and process these factual investigations, the
Level 5 Investigation Team. The primary objective of the team is be
to undertake limited-scope factual gathering investigations, which
result in a short summary report. The summary report will be a
compilation of the information the ATSB has gathered, sourced from
by individuals or organisations involved in the occurrences, on the
circumstances surrounding the occurrence and what safety action may
have been taken or identified as a result of the occurrence.
These reports will be collated and released publically on
a periodic basis.
Conducting these Level 5 investigations will have a number
of benefits:
- Publication of the circumstances surrounding a larger
number of occurrences will enable greater industry awareness of
potential safety issues and possible safety action.
- The additional information gathered will result a richer
source of information for research and statistical analysis
purposes that can be used both by ATSB research staff as well as
other stakeholders including the portfolio agencies and research
institutions.
- Reviewing the additional information will serve as a
screening process to allow decisions to be made about whether a
full investigation is warranted. This will address the issue of
'not knowing what we don't know' and ensure that the ATSB does not
miss opportunities to identify safety issues and facilitate safety
action.
- In cases where the initial decision was to conduct a full
investigation, but which, after the preliminary evidence collection
and review phase, later suggests that further resources are not
warranted, the investigation may be finalised with a short factual
report.
- It will assist Australia to more fully comply with its
obligations under ICAO Annex 13 to investigate all accidents (and
in 2010 to also investigate all serious incidents).
The implementation of these new 'short' investigations
started in December 2009, but it will take 6 to 12 months before
this new practice is adopted for all accidents and serious
incidents, as resources within the ATSB are built up to perform the
function. If you have any or questions or comments about this
initiative, please contact the ATSB's Director Safety Data,
Research and Technical, Julian Walsh on 02 6274 7548 or by email
to: julian.walsh@atsb.gov.au
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¹ High risk personal recreation/sports
aviation/experimental aircraft operations.
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