Safety issues and safety actions identified through ATSB transport safety investigations: 2009-2010 financial year


In the 2009-2010 financial year, the Australian Transport Safety Bureau (ATSB) completed 37 aviation, 10 marine, and 11 rail investigations where safety factors were identified using the ATSB analysis framework. From these investigations, 124 safety issues (factors that have a potential to adversely affect the safety of future operations) were identified and 141 safety actions were undertaken to address these safety issues. This report documents and analyses these safety issues and safety actions and explores the risk levels assigned to provide an understanding of where the greatest risks to each transport mode appear to lie. The results will be useful for government decision makers, regulators and the aviation, rail and marine industries to understand if and where attention to risk needs to be applied.

Inadequate procedures or the lack of procedures were a common safety issue found by ATSB investigations for all transport modes. In rail investigations, problems with safety management process practices were slightly more common than problems with procedures. When safety issues are assessed by the level of risk posed to transport safety, the lack of procedures or inadequate procedures were found to carry the most significant safety risk for all three modes.

Deck and flight operations were the functional areas that were associated with the most safety issues in marine and aviation investigations respectively. These were also the functional areas (along with navigation - pilotage for marine) that were linked to the majority of the safety issues carrying significant risk. For rail, vehicle maintenance and network operations were associated with the most safety issues of significant risk.

Proactive industry safety action was the most common way safety issues identified in investigations were addressed across the aviation and marine modes, while proactive industry safety actions made up only half of the safety actions taken by the rail mode.

Amending or adding procedures was a common proactive industry safety action for all modes. This was particularly the case for safety issues that carried significant safety risk. For marine, the proactive industry safety actions taken spread across various categories such as procedures, organisational supervision, documentation, education, and training. In addition, proactive changes or additions to documentation were the second most common proactive industry safety action for the aviation industry.

Type: Statistical Publication
Investigation number: XR-2010-001
Author(s): ATSB
Publication date: 21 April 2011
ISBN: 978-1-74251-155-9
Publication number: ATSB-Apr/11/ATSB28
Related: Statistics
Last update 07 April 2014
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