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'No-blame' investigations

Martin Dolan Chief Commissioner

By Martin Dolan, Chief Commissioner

Each time the ATSB publishes the report on one of its investigations, we say:

It is not a function of the ATSB to apportion blame or determine liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. 

This statement is based on what is required of us by law. More simply put, we’re not in the business of blaming people for accidents or incidents – but we are in the business of explaining what happened so we can minimise the chance of it happening again. In shorthand, we say we’re a ‘no blame’ organisation.

I’ve seen more headlines than 
I’d like that start with the words 
‘ATSB blames’. We don’t.

This approach has major benefits for improving transport safety. Our acting consistently in accordance with the ‘no blame’ principle ensures people are willing to give us lots of sensitive information without fear that the information will be used against them. This helps us understand dimensions of an accident or incident that might otherwise be unknown to us.

We use this information to identify safety issues (that is, areas where steps can be taken to reduce risks in transport safety), to promote positive safety action and to educate industry. The goal is always to improve safety. 

Despite this, it is surprising how often people read one of our investigation reports as apportioning blame. I’ve seen more headlines than I’d like that start with the words ‘ATSB blames’. We don’t.

That being said, it is sometimes the case, despite our best efforts, that the facts of an accident or occurrence speak for themselves. And sometimes we have to put those facts on the table so everyone understands what happened and why we have arrived at our conclusions.

In the same way, sometimes people assume that the ATSB should be the regulator of safety. In an overall system of safety, a regulator ensures that operators are managing safety risks well. If safety risks aren’t managed to a proper standard then, at times, the regulator will need to find fault. By contrast, our role is to understand whether the system of safety itself needs to be changed to improve safety. The two roles are complementary – but very different. 

Our investigators take our no-blame mandate very seriously. It is a foundation of their work and of ATSB culture more generally. Besides being a legislative requirement, the no-blame philosophy extends to the way we directly cooperate with anyone involved in an occurrence. We think we’re generally doing pretty well at this, but of course we always welcome feedback.

I’d be interested in your thoughts about no-blame investigations. Do you think they are an effective way to improve safety?

On a final note, I’d like to take this opportunity to wish you a happy festive season. Travel safely. I look forward to continuing our conversation on safer transport next year. 

 

Written by Martin Dolan, Chief Commissioner at 10:00 AM
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