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Mode Aviation
Reference No. AR201500076
Date reported 11 September 2015
Concern title Cabin safety investigation ability at the Australian Transport Safety Bureau (ATSB)
Concern summary

The concern related to the ATSB’s lack of cabin safety investigation ability, as it appears the ATSB have not had a dedicated cabin safety investigator since 2003.

Industry / Operation affected Aviation: Air transport
Concern subject type Aviation: Other

Reporter's concern

The reporter understands that the ATSB has not had a dedicated cabin safety investigator since 2003. The reporter highlights the limited information included in the QF 32 [AO-2010-089] report in relation to cabin safety issues despite the fact that the accident was a first of type with numerous lessons documented in the Flight Safety Foundation interview with the cabin manager. The reporter seeks feedback from the ATSB on how it manages to operate without a cabin safety specialist when its peer investigatory agencies have a demonstrated need for such expertise.

Operator's response (Operator 1)

In fact, the ATSB does retain investigators with specific training and expertise in the areas of cabin safety and survival factors. These investigators also have expertise in other investigator disciplines. Of note, one has experience in cabin safety with a major airline.

All ATSB investigators complete the ATSB’s standard investigation training for award of the Diploma of Transport Safety Investigation. The ATSB’s cabin safety/survival factors investigators have also completed the Cabin Safety Investigation course that is administered by the Southern California Safety Institute in the United States. ATSB investigators also attend and contribute to the Asia Pacific Cabin Safety Working Group.

In the past 10 years, the ATSB has done several substantial investigations into cabin safety issues. These include the following investigations, which are available on the ATSB website at www.atsb.gov.au:

  • 200502137: vacuation Hobart Airport, Boeing 717-200, VH-VQI, which involved an emergency passenger evacuation following indications of an engine fire on engine start
  • AO-2007-070: Leading edge device failure, Norfolk Island, 29 December 2007, VH-OBN, Boeing 737-229, which involved preparation for possible ditching
  • AO-2008-053: Oxygen cylinder failure and depressurisation - Boeing 747-438, VH-OJK, 475 km north-west of Manila, Philippines, 25 July 2008, which involved the use by all aircraft occupants of oxygen masks following a depressurisation
  • AO-2008-070: In-flight upset - Airbus A330-303, VH-QPA, 154 km west of Learmonth, WA, 7 October 2008, which involved multiple cabin injuries when the aircraft unexpectedly pitched down.

All of these investigations established safety issues relating to cabin safety. In all instances, safety action was taken to improve cabin safety for future operations.

In respect of the cabin safety aspects of the QF32 occurrence, these are discussed in a number of areas of the investigation report. This discussion includes a review of cabin/flight crew intercommunication and of the survival aspects following the engine failure. The ATSB determined that the flight and cabin crew response to the occurrence was in accordance with standard operating procedures and practices and no safety issues were identified. In particular, the precautionary disembarkation via the stairs likely provided the safest option when compared to the risks of an emergency evacuation into a potentially hazardous external environment.

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Last update 18 April 2016