Safety issues and safety actions identified through ATSB transport safety investigations: 2010-2011 financial year


In the 2010-2011 financial year, the Australian Transport Safety Bureau (ATSB) completed 51 aviation, 11 marine, and 8 rail investigations where safety factors (events or conditions affecting safety risk) were identified using the ATSB analysis framework. From these investigations, 121 safety issues (factors that have a potential to adversely affect the safety of future operations) were identified and 137 safety actions were undertaken by various parties to address these safety issues. This report documents and analyses these safety issues and safety actions and explores the risk levels (critical, significant or minor) assigned to them 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 were a common safety issue found by ATSB investigations for all transport modes. Specifically for rail, the design and operation of procedures were common issues. Risk controls to manage technical failures were also common in aviation. Marine investigations found that equipment problems and safety management systems were also of significant concern.

Once safety issues are identified in an investigation, they need to be addressed. Across the three transport modes, 71 per cent of safety issues of significant risk were addressed (that is, had their risk reduced to an acceptable level), while 15 per cent were only partially addressed. Only one safety issue (from marine) continues to be not addressed without any expected future safety action.

Proactive industry safety action during an investigation was the most common way that safety issues were addressed across the aviation and marine modes, while for rail the most common method of addressing safety issues was for the ATSB to issue formal Safety Advisory Notices. Only one safety issue, in aviation, was assessed to pose a critical risk to safety and was addressed by technical inspections, repairs or modifications and changes to mandatory requirements.

The most common avenue to address safety issues that posed a significant risk to aviation safety was to communicate with and/or educate those involved. For marine, changing or reviewing policy or conducting organisational surveillance were the most common ways to address significant safety issues. In rail, the most common ways to address significant safety issues  involved technical actions and policy changes .

Type: Research and Analysis Report
Investigation number: XR-2011-001
Author(s): ATSB
Publication date: 30 November 2011
ISBN: 978-1-74251-224-2
Last update 07 April 2014