Summary
The Australian Transport Safety Bureau (ATSB) is an independent
Commonwealth Government statutory Agency. The ATSB is governed by a
Commission and is entirely separate from transport policy makers,
industry operators, and from transport regulators such as the Civil
Aviation Safety Authority (CASA).
The ATSB's function is to improve safety and public confidence
in the aviation, marine and rail modes of transport 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 conduct 'no blame'
aviation safety investigations in accordance with theTransport Safety
Investigation Act 2003 (TSI Act). The ATSB does not
investigate for the purpose of taking administrative, regulatory or
criminal action.
Annex 13 (Aircraft Accident and Incident Investigation) to the
Convention on International Civil Aviation (Chicago Convention
1944) prescribes international principles for aircraft accident and
incident investigation, and the provisions of the
TSI Act are designed to reflect those principles..
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 and the most 'serious incidents', as
defined by Annex 13, have priority for investigation. The Bureau
investigates selectively, as do many equivalent organisations
overseas. The aim is to concentrate ATSB's resources on those
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 resources. 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, identify
any safety issues, and encourage relevant safety action. The aim of
all ATSB investigations is to 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 for the purposes of improving safety in the future.
Reporting
accidents and incidents
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 that 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 so that the information can be used in future
safety research and analysis. Please call the toll-free number
1800 011 034 to notify the ATSB.
Refer to the TSI Regulations for a list of all
reportable occurrences and responsible persons who
are required to report them to the ATSB.
The ATSB operates Australia's REPCON Scheme
which offers people in the aviation industry the opportunity to
report unsafe conditions, practices or procedures involving
aircraft without fear of being identified. For more information
about REPCON phone 1800 020 505 or e-mail repcon@atsb.gov.au
The
investigation
On receiving a report of an accident or serious incident, the
ATSB will decide what action to take. Depending on the type and
severity, this may be:
- an on-site investigation carried out by investigators;
- a request for more information from an owner, employer or other
party; or
- an entry of accident or incident details into the ATSB's
database.
On-site investigations are detailed investigations where
investigators travel to the site of the accident. 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 have declared that it is safe. The investigators
photograph and record all the evidence on the ground or associated
with the wreckage of the aircraft, 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. Consistent with
international practices, it is accepted protocol for ATSB
investigators to seek information or assistance in a manner that
encourages cooperation and the ATSB will liaise with other parties
who have an interest.
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 necessary, 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 may have been
in contact with the pilot either during or before the flight. They
will generally 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 takeoff,
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, and 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 discuss the expected progress of
the investigation.
Sensitive evidence collected in the course of an investigation
is classified as restricted information under the provisions of the
TSI Act. The Act contains confidentiality provisions, which prevent
this restricted information from being made freely available for
purposes other than transport safety. Importantly, this includes
self-incrimination immunity for persons who are required to attend
before the ATSB under powers of the TSI Act. Information provided
under these circumstances cannot be used against the person in
criminal or civil proceedings.
ATSB
reports
When an ATSB investigation is undertaken, a report is completed
for public release. Investigation reports 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. That can include overseas investigation
agencies, regulators, and manufacturers. Often the safety factors
identified by the investigation turn out to be very different from
the explanations proposed in the media immediately after the
event.
The ATSB will send a draft copy of the report to directly
involved parties or their representatives. Those parties 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. They will normally have at least several
weeks to respond before the report is finalised.
Directly involved individuals and organisations will receive an
advance copy of the final report. Extra copies will be published on
the day of the report's public release, either in printed form, or
on the ATSB website at www.atsb.gov.au.
ATSB investigation reports and most evidence collected during an
investigation cannot be used in civil or criminal proceedings. ATSB
investigation reports may be used in coronial inquiries for the
purpose of improving safety.
Safety
action
'Safety action' is the term used to describe any action taken by
organisations and individuals in response to the safety issues that
were identified during an investigation. The aim of any safety
action is to prevent similar accidents and incidents.
The ATSB facilitates safety action by communicating the
identified safety issues to the relevant organisations throughout
the course of an investigation. The ATSB encourages proactive
safety action and will acknowledge such action in its investigation
reports.
Formal safety recommendations are normally issued when other
attempts to facilitate safety action have been unsuccessful, and
the risk level is considered by the ATSB to be either critical or
significant. The ATSB has no legislative power to enforce its
safety recommendations, but it can require a detailed response
which may be made public, regarding the implementation of
recommendations.
Coronial
inquests into an aviation accident
The relevant State or Territory Coroner may hold an inquest into
a fatal aviation accident. The Coronial inquest and the ATSB
investigation are separate but they do interact.
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. Coronial services can also offer assistance and
advice, and some Coronial jurisdictions provide grief counselling
and other support for relatives by means of trained
professionals.
| Type: |
Corporate Brochure |
| Publication Date: |
01/07/2009 |
