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Michele Khoury said...

Let us all remain "InFocus". A great initiative that needs input from all stakeholders in the Transport industry.You're only as good as the next Blog!!

November 22, 2012 11:53
$$$ said...

Fatigue = Human Error ... But you already knew that

November 22, 2012 12:18
John Lambert said...

I have seen ATSB reports relating to all modes (a couple of marine reports, a small number of aviation reports, and many rail reports). I have been very dissappointed in the rail investigations in so far as to a significant degree they do not take a complete approach to the task. All vehicles including rail vehicles are not evaluated to the same degree as to the design and operational aspects that contribute to crashes and or trauma; all operators of vehicles and machinery including train crew are not evaluated to the same degree as to the contribution of their driving behaviour, distraction, fatigue...; and so on. I have on occasions sent detailed criticisms of reports only to get defensive responses that reflect no interest in ensuring the maximum improvement in rail system safety. How does one influence ATSB to do a better job?

November 22, 2012 12:47
Martin Dolan, Chief Commissioner (author) said...

Thank you for the feedback. We are always looking to improve what we do. We also try to respond whenever we receive constructive feedback on our reports. There is a comments function for the web version of each report. Comments can also be sent direct to ATSBInfo@atsb.gov.au

Unfortunately we haven’t been able to find your earlier feedback. If you’d like to resend them, our rail team would be happy to respond.

In the meantime, I can give at least a partial answer to your question. The methodology we use for rail investigations is identical to that used in marine and aviation investigations. In the course of an investigation, we do a great deal of work to identify the safety factors and issues relevant to the accident or incident. We also consider and eliminate a range of other possible factors including, technical and human factors, but this work is not generally included in detail in the final reports. This is because we focus our investigation effort and the content of our reports on identifying and reporting the safety factors and issues which we think are the most significant and most likely to result in action leading to safety improvements.

November 24, 2012 11:09
Kuya said...

I'm a coach driver. I drive miners from the mine camps to the mine and back every day. At the end of the seven day, 84 hour shift the miners return to the camp, get in their cars and drive to Cairns or Townsville or even Byron Bay. All the fatigue management that is put in place by the mines is lost and the accident rate even among the shifts that I carry on my coach is staggering.

I have no ideas about how to address this.

November 22, 2012 13:23
Peter J. Cesnik said...

As an Australian who has retired in Europe I still follow Australian transport (road and aviation) daily. I am suscribed to Australian Aviation. The Australian practices are closely watched and in many cases followed in EU (or at least some parts of EU). Such a blog is a welcome addition to already great internet application that is managed by ATSB...so keep a good work.
As far as the comments the comments by Kuya goes - this problem exists in Europe as well. There are many workers through Europe who hail from Romania, Bulgaria and other south eastern European countries. On the occassions of longer holiday breaks (Easter) these people drive from Spain to Rumania...the distance equivalent to the distance Adelaide - Brisbane. In many instances with tragic results. minivans are being to some extend monitored but not personal vehicles. More policing is perhaps not the solution, but education is...

November 22, 2012 20:10
Harry Horlings said...

Thank you Mr. Dolan for this opportunity to get into contact with you directly. I've tried to contact ATSB quite a few times during the past 7 years, writing letters and e-mails, but never received an appropriate response. I feel like being treated as a 10 year old, while I am 64 and a highly experienced flight test expert after being trained at the USAF Test Pilot School in 1985. This is a post MSc level one-year long training for experimental flight testing airplanes, first flight or modified. The training included engine-out testing. 
After reading many investigation reports of accidents after engine failure with multi-engine airplanes, I noticed that pilots and investigators explain and use a flight manual published airspeed minimum (Vmca) in a different way than we in flight test determined this; the conditions for which this speed is valid got lost in manuals and are obviously unknown to pilots and also to investigators. 
I started writing papers for improving the knowledge on the subject, including a 70-page paper for accident investigators. 
Following another letter, I was invited to publish an article in FSA, but after mailing it to the editor, I never heard from them again. ATSB might not like high level airplane knowledge and experience, is what crossed my mind. 
Please visit the downloads page of my website. After reading and understanding the paper(s), your investigators will improve conclusions and recommendations and really make aviation safer. 
Please don't ask regular pilots for an opinion on my work, because they don't know (yet), but find an experimental test pilot in the RAAF or elsewhere; he or she will agree, because they learned the same thing and did not crash during flight with an inoperative engine. 
I am always willing to assist in making aviation safer, for instance by training pilots and investigators.

November 22, 2012 21:28
SV said...

As a mariner, I can tell you that much: as long as commercial interests have priority over proper fatigue management, human errors and consequently, maritime accidents, incidents and near misses will not be reduced in the industry.

November 23, 2012 05:12
Barry Payne said...

As the retired Principle Brake Engineer for QR(now QRN and QR)I know that the Brare Engineers know very accurately the stopping distances of trains in QR and QRN over any gradient. I believe that this system which has taken many years to perfect should be purcahsed by all of the Australian Railways from QRN and QR and the initial expertise to show these railways how to gather the rollingstock braking knowledge

November 23, 2012 12:56
Martin Dolan, Chief Commissioner (author) said...

Thank you to everyone who contributed to my first InFocus post. The response is encouraging and I’m pleased to see a strong interest in the work we do to improve transport safety.

To briefly touch on some of the points raised, the ATSB recognises that fatigue is an ongoing safety risk that needs heightened attention and effective management. We have identified fatigue as a significant safety risk in several investigations including the Shen Neng 1 grounding and in Queensland’s coastal pilotage operations.

Thanks to strong and mature safety systems, Australian transport operators generally manage fatigue risks well. However, we also consider that there is room for improvement, particularly for smaller aviation operators and in the maritime pilotage industry more generally (see the Maritime Pilotage safety priority on our Safety Watch page).

Several of our people have a strong background in fatigue assessment and management and we will continue to make sure that we examine possible fatigue issues whenever they are relevant to an investigation.
In my next blog post, I’ll be talking more about our safety systems that aim to reduce the risk of human error brought on by such things as fatigue.


November 30, 2012 11:34
machinery transport said...

Great blog indeed! Thanks for sharing your thoughts.

January 9, 2013 14:04
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