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Focusing our investigative resources

By Martin Dolan, Chief CommissionerMartin Dolan

We often get asked how we decide whether to investigate a particular accident or incident that’s reported to us. 

To help answer this question, it’s important to provide a bit of context. 

The ATSB receives more than 15,000 safety occurrence reports from the aviation, maritime and rail transport industries each year. Of these reports, around 8,000 are assessed as accidents or incidents—and the vast majority are reports of minor incidents.  

The ATSB carefully assesses the large volume of occurrence reports for two purposes: to maintain and expand an accurate database of safety occurrences; and to decide whether a particular occurrence merits an investigation. Having such a database is important to our job of improving transport safety, since it lets us see trends that are not obvious from a single event and know how often a particular type of event is happening. 

...we direct our investigative resources to accidents and incidents involving operations that have mature safety systems and will likely uncover a safety benefit or improvement for industry and the travelling public. 

Put another way, occurrence data helps inform our decision about whether or not to investigate. When making this decision, the ATSB needs to ensure it directs its resources to what is more likely to reveal systemic safety issues or lessons, or to enhance safety for the travelling public and the transport industry. 

In aviation, the ATSB aims to investigate most accidents and serious occurrences. That said, we focus our attention on the safety of the travelling public. As a result, we generally do not investigate private activities such as sport and recreational flying where there is a voluntary acceptance of a higher level of risk. Those sectors of aviation are largely self-administering and have their own investigation capabilities, working with the police and coroners in the case of fatal accidents. 

Similarly for the maritime and rail industries, we direct our investigative resources to accidents and incidents involving operations that have mature safety systems and will likely uncover a safety benefit or improvement for industry and the travelling public. 

While the ATSB can’t investigate every accident or incident reported to us, we are still conducting around 130 investigations at any given time, as shown on our active investigations map. I encourage you to check the map out to see the types of investigations that are likely to reveal safety lessons that will ultimately enhance transport safety in Australia.

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


Geoff Chatfield said...

Dear Sir
As an avid aviation enthusiast I was wondering if there has been any thought given to returning Mark/Registrations to the Aviation Weekly Summaries.
Yes I know we have got by with keeping an historical record of aircraft here in Australia since the Marks/Registrations were removed but with that information in place we are able to keep more historically records due to the fact that we are able to place where an accident/incident has occured when CASA has deregistered an aircraft due to an accident/incident.

May 15, 2013 16:56
Martin Dolan, Chief Commissioner (author) said...

We only publish aircraft registration data for occurrences we investigate. We don't publish similar information for non-investigated occurrences because the information isn't verified, and, more importantly, there are privacy considerations we must observe.

May 17, 2013 09:21
Frank McNulty said...

I can appreciate the number of detailed investigations required for those with mature (ISM) safety systems, the vast areas, the priority environmental conservation areas.
Given that, I was reading through Queensland's record yesterday and found an alarming number of collisions, drownings from no buoyancy aids etc. Here is the url link to simple poster that a lecturer at our national maritime college posted on his facebook page -taken from the ISA website. That said at least you've got the statistics. Keep up the good work.
In Ireland the trend has been losses in 17-25 metre fishing boats , despite efforts on PFDs, licences linked to safety equipment musters.
These are my own impressions.

May 15, 2013 18:55
Martin Dolan, Chief Commissioner (author) said...

At present in Australia, the Commonwealth Government’s maritime safety jurisdiction is mostly limited to overseas passenger and cargo vessels operating in Australian waters, Australian passenger or cargo vessels on inter-state or overseas voyages and Australian fishing vessels on overseas voyages. Since the ATSB is a Commonwealth agency, our investigations – and our resources – are for mostly limited in the same way.

Correspondingly, State governments have responsibility for the safety regulation of other commercial and recreational vessels and investigating incidents involving such vessels.

From 1 July this year, there will be a single national arrangement for the safety regulation of commercial vessels, but the governments that agreed to this arrangement did not see the need to give resources to the ATSB to expand its safety role to include all commercial vessels. That means we will continue to focus on incidents involving larger passenger and cargo vessels.

We agree that there is a continuing level of safety concern with smaller vessels, including collisions and drownings. In many cases they reflect what we see with smaller aircraft: the same accidents happening over and over. The best way to tackle these problems would seem to involve clear, targeted safety education about how accidents can be avoided – as many of them are easily avoidable.

May 17, 2013 09:32
Tony Taggart said...

I fully understand, accept and support the explanation given, but I can't help thinking that sometimes pilotics comes into play and accidents with high profile people that would not otherwise be tackled are resourced up.
Is this a misconception or is there an element of truth?
Best wishes

May 16, 2013 16:51
Martin Dolan, Chief Commissioner (author) said...

I wouldn’t say it’s a matter of politics, Tony. It’s true that our Minister can direct us to investigate a particular matter (a power that has only been used once, well before my time), but there’s no power to prevent us from investigating something. When an accident has a high public profile, though, that is one of the considerations we openly take account of in deciding whether to investigate. We recognise that the community sometimes expects we will try and find out what happened, even when it’s unlikely that we’ll learn something to improve safety. As we’ve been saying for some time, there are many accidents in general aviation that have known and avoidable causes and where the most effective safety action is education rather than investigation.

May 17, 2013 11:18
Martin Smith said...

Mr Dolan,

In one of your reply's you mention that the Minister has the power to direct you to investigate a particular matter.
In your opinion should he now direct the ATSB to re-investigate the pel-air ditching and recover that particular westwinds data recorder?

May 30, 2013 21:30
Martin Dolan, Chief Commissioner (author) said...

A Senate committee has made a number of recommendations to the ATSB, including that we re-open the investigation and recover the recorders. The ATSB will carefully consider those recommendations - and others relevant to us - and respond to them. Until we have done that, we won’t be commenting on those recommendations.

May 31, 2013 09:56