How ATSB safety investigation reports are organised
ATSB investigation reports are organised in accordance with international
standards or instruments, as applicable, and with ATSB procedures and guidelines.
Reports normally contain the following main parts:
Part 1: Factual information
Provides objective information that is pertinent to the understanding of the
circumstances surrounding the occurrence
Part 2: Analysis
Discusses and evaluates the factual information presented in Part 1 that the
ATSB considered when determining its findings and safety actions.
Part 3: Findings
Based on the analysis of the factual information, presents three categories
of findings; contributing safety factors; other safety factors; and other
key findings.
Part 4: Safety action
Based on the findings of the investigation, records the main local actions
already taken or being taken by the stakeholders involved, and recommends
safety actions required to be taken to eliminate or mitigate safety issues.
Part 5: Appendixes
Contains additional information that supports the report, for example, specialist
reports on materials failure or flight data analysis.
Note: Not all parts described above will be applicable in
all circumstances. Reports of less complex investigations, for example, may
not include safety action or appendixes.
Terminology used in ATSB safety investigation reports
Occurrence: accident or incident.
Safety factor: an event or condition that increases safety
risk. In other words, it is something that, if it occurred in the future, would
increase the likelihood of an occurrence, and/or the severity of the adverse
consequences associated with an occurrence. Safety factors include the occurrence
events (e.g. engine failure, signal passed at danger, grounding), individual
actions (e.g. errors and violations), local conditions, risk controls and organisational
influences.
Contributing safety factor: a safety factor that, if it had
not occurred or existed at the relevant time, then either: (a) the occurrence
would probably not have occurred; or (b) the adverse consequences associated
with the occurrence would probably not have occurred or have been as serious,
or (c) another contributing safety factor would probably not have occurred
or existed.
Other safety factor: a safety factor identified during an
occurrence investigation which did not meet the definition of contributing
safety factor but was still considered to be important to communicate in an
investigation report.
Other key finding: any finding, other than that associated
with safety factors, considered important to include in an investigation report.
Such findings may resolve ambiguity or controversy, describe possible scenarios
or safety factors when firm safety factor findings were not able to be made,
or note events or conditions which ‘saved the day’ or played an
important role in reducing the risk associated with an occurrence.
Safety issue: a safety factor that (a) can reasonably be
regarded as having the potential to adversely affect the safety of future operations,
and (b) is a characteristic of an organisation or a system, rather than a characteristic
of a specific individual, or characteristic of an operational environment at
a specific point in time.
Safety issues can broadly be classified in terms of their level of risk as
follows:
Critical safety issue: associated with an intolerable level of risk.
Significant safety issue: associated with a risk level regarded as acceptable
only if it is kept as low as reasonably practicable.
Minor safety issue: associated with a broadly acceptable level of risk.
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