Summary
October Audit Report of the Australian Transport Safety Bureau (ATSB) of Australia
(Field work conducted in Canberra, 31 May to 4 June 2004)
Executive Summary
The ICAO audit team commended the positive and professional approach of the
ATSB in proactively seeking the audit. The team was highly satisfied with the
legislative and organizational framework established by Australia and the ATSB
enabling the conduct of aircraft accident and incident investigations. Nevertheless,
the audit focussed on all areas related to accident and incident investigation
and found possible areas of improvement.
The Transport Safety Investigation Act 2003 (TSI Act) is the legislative
framework for transport safety investigations in aviation, marine and the interstate
rail system. The TSI Regulations 2003, giving effect to the TSI Act,
came into force at the same time as the TSI Act on 1 July 2003. Together, the
TSI Act and the TSI Regulations comply with Annex 13 requirements and have the
necessary provisions to enable the ATSB to effectively conduct or participate
in aircraft accident and incident investigations. The ATSB has notified its
differences to ICAO in respect of Annex 13. While section 17 of the TSI Act
automatically endorses any amendments to ICAO SARPs and gives them the force
of Australian law, the ATSB has not yet formalized its process for reviewing
the SARPs and identifying its differences.
The ATSB has its headquarters in Canberra and two regional offices (in Brisbane
and Perth). The ATSB is adequately organized and supported by appropriate technical
and non-technical staff. However, the ATSB has not established a process for
determining staff requirements needed to adequately complete all tasks in its
area of responsibility. When establishing its Business Plan, the ATSB
took into consideration the Departments Portfolio Budget Statements; however,
the ATSB developed the performance indicators of its business plan based on
the budget allotted to it. As a result, the number of smaller investigations
and the scope of more complex investigations change depending on the availability
of financial resources. Ideally, the number of accidents, serious incidents
and associated safety issues should be used as a basis for the determination
of the budget. Finally, the ATSB has not put in place a system for the control
and integration of the regional offices into the functionality and organizational
structure of the Canberra office. The ASTB has signed several Memorandums of
Understanding (MOUs) with other organizations and authorities but some important
MOUs have yet to be finalized.
The ATSB is commended for having developed a very comprehensive training policy
and programme, which includes a diploma course entitled Transport Safety Investigation
(TSI) Diploma Course. The ATSB training policy requires all personnel who joined
the ATSB after 1 January 2000 to complete the TSI Diploma Course. Investigators
who have taken or are currently taking this course maintain structured training
files in accordance to the training programme followed. However, not all investigators
have undergone the TSI Diploma Course. As a result, some investigators are not
part of the formal diploma programme and do not maintain a documented record
of all the types of training and briefings that they have been provided with.
The ATSB provides its staff with all the necessary facilities and equipment.
However, the review of some of the equipment to be used by investigators revealed
shortcomings in serviceability and record keeping. The ATSB has developed a
new Safety Investigation Policy and Procedures Manual but has not yet
formally approved it. The procedures established by the ATSB for the notification,
investigation and reporting of aircraft accidents and incidents, found in several
manuals, are comprehensive and in conformity with Annex 13 requirements. The
ATSB focuses primarily on fare-paying passengers and on fatal accidents (unless
they involve sport aviation), therefore some accidents that are considered to
have little potential benefit for the prevention of re-occurrences may not be
investigated in detail. In such cases, the ATSB does not necessarily attend
the scene, conduct an in-depth investigation or produce an extensive report.
Autopsy reports are obtained by the ATSB but are not always complete. By Australian
legislation, medical examination and toxicological testing of surviving flight
crew and aviation personnel cannot be performed after an accident.
Safety recommendations are issued by the ATSB in conformity with Annex 13 requirements.
ADREP Preliminary Reports and Data Reports sent by the ATSB to ICAO were incomplete,
partly due to the differences in the taxonomy format. Since the ATSB is in the
process of acquiring a new accident and incident data reporting system, it is
recommended that the new database system be ADREP-ECCAIRS compatible in order
to facilitate reporting and international exchange of data. Between 1988 and
February 2004, the ATSB managed a voluntary incident reporting system named
Confidential Aviation Incident Reporting (CAIR). A new voluntary non-punitive
incident reporting scheme, entitled Aviation Self-Reporting Scheme (ASRS), replaced
the CAIR on 21 February 2004 but has not yet been broadened to receive CAIR
reports, pending further legislative measures. In addition to accident and incident
investigation, the ATSB undertakes safety data analysis and research. All the
ATSB reports, safety recommendations and key safety information are available
on the ATSB website.
Updated January 2008
Download Complete Document: ICAO_audit [ PDF: 2925Kb]
Type: Research and Analysis Report
Publication Date: 22/10/04
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