Summary
The Australian Transport Safety Bureau (ATSB) is an operationally independent
body within the Australian Government Department of Infrastructure, Transport, Regional Development and Local Government
and is Australia’s prime agency for transport safety investigations. The
ATSB’s objective is safe transport. Its mission is to maintain and improve
transport safety and public confidence through excellence in:
- independent investigation of transport accidents and other safety occurrences;
- safety data recording, analysis and research; and
- fostering safety awareness, knowledge and action.
In the aviation transport mode the ATSB conducts ‘no blame’ aviation
safety investigations in accordance with the provisions of Annex 13 to the Convention
on International Civil Aviation (Chicago Convention 1944), which have been incorporated
into Australian law through the Transport Safety Investigation Act 2003
(TSI Act). The Bureau is entirely separate from transport regulators such as
the Civil Aviation Safety Authority (CASA) and from service providers such as
Airservices Australia.
Does the ATSB investigate all aviation accidents?
The ATSB’s primary focus is on fare-paying passenger safety but it investigates
most fatal accidents (other than those involving sport aviation). Accidents as
defined by Annex 13 have priority for investigation as do the most significant
‘serious incidents’. The bureau investigates selectively, as do many
equivalent organisations overseas. The aim is to concentrate ATSB’s resources
on in-depth investigations considered most likely to enhance aviation safety.
Because many accidents are repetitive in nature, investigating these in any detail
may not be justified, given the bureau’s limited budget. In such cases,
the ATSB will not necessarily attend the scene, conduct an in-depth investigation
or produce an extensive report.
When the ATSB investigates an accident or incident, investigators will seek to
determine its circumstances, encourage relevant safety action and make any necessary
safety recommendations. Their role is to help prevent the occurrence of other
accidents and incidents rather than to assign blame or liability. This approach
helps ensure the continued free flow of safety information. The bureau may also
scale down and finalise an investigation once investigators have determined the
safety factors. The ATSB is not a regulatory authority and therefore cannot enforce its recommendations. It relies on its reputation, analysis and wide dissemination of findings
for recommendations to be adopted.
When an aviation accident or serious incident occurs
As required under the Transport Safety Investigation Regulations 2003 (TSI Regulations),
the owner, operator or crew of an aircraft must report an accident or serious
incident to the ATSB as soon as practicable and by the quickest means possible.
While both the crew and the owner must report the occurrence immediately, it is
understood that the owner may not learn of the accident until some time after
the event, and the crew may be unable to notify the ATSB due to personal injuries.
Anyone else learning of an aviation accident should, in addition to alerting emergency
services as required, report the accident to the ATSB immediately. While the ATSB
does not investigate all accidents and incidents, it still needs to be notified
of all aviation occurrences (refer to the TSI Regulations on the ATSB website
for a list of all reportable occurrences and responsible persons for reporting)
so that the information can be used in future safety analysis. Please call the
toll-free number 1800 011 034 to notify the ATSB.
As soon as the ATSB has been notified of an accident, it will liaise with bodies
such as Police, Emergency Services, Air Traffic Control, Coroners and the aircraft
operator to ensure that evidence associated with the accident is secured pending
examination. Investigators may be dispatched to the accident site to conduct the
investigation.
Investigators’ powers
The ATSB is only concerned with future safety. Therefore, the powers contained
within the TSI Act cannot be used against individuals or companies for any role
they may have played in a transport safety occurrence. Investigators may wish
to interview persons directly or indirectly involved with an accident or incident
or to remove and retain relevant documentation and physical evidence for further
examination and analysis. Additionally, investigators may need to enter premises
including accident sites, vehicles, buildings and other places to complete their
investigations.
Consistent with international practices, it is accepted protocol for ATSB investigators
to seek to obtain information or assistance in a manner that encourages cooperation.
However, where multiple and conflicting interests are associated with the subject
matter of an investigation, the powers to access information must match the potential
incentive to deliberately tamper with or destroy evidence or to withhold or provide
false information. Where such powers are exercised, a number of checks and balances
in the TSI Act ensure that those powers are strictly controlled.
Section 32 of the TSI Act provides a power to require persons to attend before
the Executive Director to answer questions or produce evidential material. The
requirement must be in writing and the person must be given reasonable time to
attend.
Importantly, this includes self-incrimination immunity for persons who are required
to attend before the Executive Director under section 32. Information provided
to the Executive Director in those circumstances cannot be used against the person
in criminal or civil proceedings.
Section 33 of the TSI Act allows ATSB investigators to enter Special Premises
(accident sites and vehicles) without a warrant or consent but those powers are
limited to the investigation of accidents and serious incidents. Any evidence
seized following the exercise of the Special Premises power must be directly relevant
to the investigation and can only be seized where there are reasonable grounds
to believe that the preservation of or timely access to critical evidence is at
risk.
The investigation
The field phase of the investigation begins at the accident site. ATSB investigators
are responsible for the wreckage and the site’s safety when control of the
site is handed over to the ATSB after emergency services declare that it is safe.
They will photograph and record all the evidence on the ground and later examine
the aircraft’s logbooks and maintenance records. They may then arrange for
the aircraft wreckage, components and other material evidence to be transported
to the bureau’s Canberra office, or some other secure area, for further
examination and testing.
Wreckage not required for examination by the ATSB, or other investigating
organisations with a right to it, is the responsibility of the owner, the owner’s
estate or the aircraft insurers. Personal effects not relevant to the investigation
will be handed to the Police for safe custody.
To reconstruct the sequence of events preceding the accident, ATSB investigators
will, where possible, interview the pilot, passengers and other witnesses.
They may also visit the departure and destination airfields and interview the
pilot’s acquaintances and officials including air traffic controllers who
came in contact with the pilot before the flight. They will ask for records relating
to the pilot’s training and experience and may require company documents
relating to the aircraft’s operation. They will also require data concerning
airfield operations if the accident occurred during the take-off, approach or
landing phase of flight. Maintenance records and interviews with maintenance personnel
may also be required.
Investigators will sometimes need to interview the pilot’s next of kin to
understand the pilot’s background or to examine professional documents or
certificates kept at home. This is often an emotional time and investigators always
contact the families before visiting. Such meetings allow the next of kin to meet
the investigators personally and to question them about the handling and progress
of the investigation.
The investigators will present their initial findings to ATSB management who will
then decide how the investigation should proceed and what form the report should
take.
When the factors which led to a fatal accident are not obvious, the media and
the public often speculate about what happened. This can be very distressing for
the next of kin.
The ATSB is committed to regularly updating the next of kin concerning the known
facts of the investigation. Where appropriate and possible, it will privately
brief the next of kin and immediate family before the final report is published.
The report
An investigation report can take many months to produce. It may be necessary to
interview numerous individuals, cross-check evidence, examine suspect equipment
and consult other technical experts. Often the contributing factors identified
by the investigation turn out to be very different from the explanations proposed
in the media immediately after the event.
The report will not seek to apportion blame.
As required under the TSI Act, no one will be able to use the report to determine
liability. If appropriate, the report will include safety recommendations. The
ATSB will send a draft copy of the report to directly involved parties or their
representatives. These will include individuals or organisations whose reputations
may be adversely affected by the report. Under the TSI Act, recipients are required
not to copy or disclose the contents of the draft report except for the purpose
of providing comments to the ATSB on the draft report or to take safety action
in response to the report’s findings. They will normally have at least several
weeks to respond before the report is finalised.
Directly involved individuals and organisations will receive a printed copy of
the final report. Extra copies will be published either in printed form or through
the ATSB website www.atsb.gov.au
Inquests or inquiries into the accident
The state or territory coroner may hold an inquest into a fatal aviation accident.
The coronial investigation and the ATSB investigation are complementary.
Coroners may request the custody of wreckage and any other item carried on
the aircraft at any stage of the investigation. If custody is requested in writing,
the requested items would normally be released on completion of the ATSB’s
examination of them in accordance with section 45 of the TSI Act.
ATSB investigators may be legally required to appear as expert witnesses. A date
for an inquest or inquiry is determined by the coroner.
The Coroner’s Office should be contacted on all matters relating to an inquest
or inquiry. Coronial services can also offer face to face assistance and advice,
and some Coronial jurisdictions provide grief counselling and other support by
means of trained professionals.
Download Complete Document: Air_safety_in_Austra [ PDF: 1377Kb]
Type: Corporate Brochure
Publication Date: 06/06/08
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