Why is the ATSB doing this research?
Each year, the ATSB conducts investigations into transport safety matters in aviation, rail and marine. Most of these reports document safety issues (factors that have a potential to adversely affect the safety of future operations) identified during the investigation, along with the assigned risk level for each safety issue. The ATSB also individually documents safety actions completed by industry or regulators in response to the identified safety issues. When no or inadequate safety action occurs, the ATSB may also release a safety recommendation, which is required to be responded to within 90 days.
This report documents the ATSB identified safety issues and related safety actions and recommendations for the 2011–12 financial year and trends across 3 financial years. It will explore the risk levels assigned and provide an understanding of where the greatest risks to each transport sector appears to lie, based on investigation findings. 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.
What the ATSB found
In the 2011–12 financial year, the ATSB completed 56 occurrence investigations into air transport, general aviation, rail and marine accidents and incidents. These investigations identified 100 safety issues, of which 28 posed a significant risk to safe ongoing operations and required safety action. More significant issues were identified in marine operations than in any other transport sector. Most safety issues were addressed with safety actions, especially those taken proactively by industry (more than 90 per cent of all safety actions).
The types of safety issues identified in investigations completed in 2011–12 were similar to those found in previous financial years, though there were more issues relating to marine operations, and less relating to general aviation. Safety issues were most often found with risk controls, particularly procedures. Safety management processes of organisations were an emerging issue in marine accidents and incidents in 2011–12, as were on-vehicle safety procedures and equipment in rail.
In all transport sectors, the most commonly identified safety factors that contributed to the accident or incident were the actions of individuals. In aviation, aircraft operation actions usually contributed to accidents and incidents – in marine, navigation and deck operation actions, and in rail operations, maintenance and vehicle operation actions most commonly contributed. Effects of local conditions (such as weather, training and skill level, workload, stress or fatigue) were common contributors to accidents and incidents.
The ATSB plays a central role in identifying where areas of safety concern exist in Australia’s transport system. While investigations tend to show that individual actions contribute to most accidents and incidents, there are many latent safety issues that have the potential to cause further accidents if not addressed. Issues with training, fatigue, operating procedures, and the quality of safety management systems frequently contribute to accidents, and are wholly avoidable.
The ATSB continues to promote safety actions initiated by industry as the most timely and effective way to drive safety improvements to close identified gaps in safety. The misfortunes of others are a timely reminder to everyone involved in transport to look for similar safety risks in their operation that could lead to a similar accident or serious incident.