We understand that any accident that results in a serious injury or loss of life has profound effects and may involve a complex process of grieving for those close to the individuals involved.
Families and friends naturally want to know why the accident happened, and how to prevent someone else having to experience such loss.
This page attempts to answer some of your questions about a transport safety investigation conducted by the Australian Transport Safety Bureau (ATSB) where there has been a loss of life and/or serious injury.
What is the ATSB?
The ATSB is an independent Commonwealth Government statutory agency established under the Transport Safety Investigation Act 2003 (TSI Act). The ATSB is governed by a Commission and is entirely separate from transport regulators, policy makers and service providers.
The ATSB investigates accidents and incidents to find out what happened to prevent it from happening again.
In accordance with the TSI Act, the ATSB cannot apportion blame, assist in determining liability or, as a general rule, assist in court proceedings, and we are required to be independent, in the interests of avoiding conflicts of interest and external interference in our role.
Our sole focus is the prevention of future accidents and the improvement of transport safety.
What is an IIC?
Assigned by the ATSB, the Investigator-In-Charge (IIC) is responsible for leading the safety investigation and manages all aspects of the investigative process through to its conclusion. Depending on the circumstances of the accident, the IIC may travel to the accident site to collect information. Typically, the IIC is the main point of contact for those affected by an accident, however in some cases, the ATSB may appoint a dedicated liaison officer who is not the IIC.
Accident investigations
Process
Due to the possible complexity of accident investigations and the extensive nature of the investigation process, an investigation can require 6 to 24 months to complete.
The onsite phase of the investigation may take several days or weeks. The ATSB will not determine accident findings while on site.
To gather relevant information, the ATSB may:
- retain components of the vehicle or onboard documents
- interview witnesses and other relevant persons
- obtain additional information relevant to the investigation from a number of different sources, for example, maintenance records, operating procedures, and weather information
- conduct tests and research, as appropriate
- analyse available data, for example, onboard recorders and electronic devices, air traffic control recordings, and other media.
Personal information
The ATSB will likely need to ask you some questions to better understand the activities of involved persons in the days before the accident.
In this situation, you may be asked for information on your loved one’s recent rest periods, sleeping patterns, medication, general state of health, work history and other aspects.
While these are routine questions for any investigation and help us to exclude certain factors, discussing these matters in such circumstances may be difficult, so we encourage you to consider having another family member or friend available for support during the discussion.
Personal effects
The ATSB may take custody of personal effects like personal electronic devices or other items relevant to the investigation. Depending on condition, these items may be returned to the owner or a designated family member. Typically, this will occur at the conclusion of the investigation.
Personal effects not collected by the ATSB may be collected by the Coroner or another agency involved in the response.
Investigation reports
The ATSB will release a final report at the conclusion of an investigation. However, at any time during an investigation, should we uncover safety critical information we will immediately share that with relevant parties so they can take appropriate safety action.
Depending on the complexity of the accident and the scope of the investigation, the ATSB may also publish preliminary and interim reports:
- A preliminary report details factual information determined in an investigation’s initial evidence collection phase and areas of ongoing investigation. They are typically released about 1 to 4 months after the accident.
- An interim report details more extensive factual information and outlines areas of ongoing investigation.
- The final report details contributing factors, safety issues and other findings.
The ATSB provides copies of final investigation reports to the public and the reports are made available on our website. However, a copy of the final report will normally be available to you and your immediate family a number of days before its public release.
ATSB transport safety reports do not include the names of individuals. In many situations, however, an individual’s role (for example, the pilot in command, ship’s master, locomotive driver) may be stated to describe the occurrence.
Other agencies
The TSI Act enables strong protections on evidence gathered during an investigation. This ensures the protection of information provided to the ATSB, generally prevents the ATSB from sharing any information collected, and is crucial to maintaining our independence from other agencies. As such, other organisations may seek to obtain information from you, that you have already provided to the ATSB.
Other organisations may also undertake a separate investigation into an accident. The intent and/or processes of these investigations will differ to those of the ATSB.
Coroner
Your state or territory Coroner is required to undertake an investigation to determine the identity of a deceased person and the date, place, circumstances and medical cause of death. The police usually coordinate this investigation on behalf of the Coroner.
The Coroner may also hold an inquest or inquiry into a fatal transport accident. All queries relating to an inquest or inquiry, or to any police investigation carried out for the Coroner, should be directed to your Coroner’s Office.
Coronial services can also offer face-to-face assistance and advice, and most Coronial jurisdictions provide grief counselling and other support by trained professionals. A list of those and other relevant support services are enclosed.
Post-mortem examinations
A post-mortem (or autopsy) is usually ordered by the Coroner of operating crew, and sometimes passengers, to ensure that they can deliver an accurate finding regarding the cause of death. These findings can enable the ATSB in identifying any medical conditions/factors to assist in performing its role of improving transport safety.
Regulatory authorities
Our independence from regulators and policy makers means the ATSB does not have powers to force operators, manufacturers or regulators to take safety action. Instead, we seek to influence safety action through engaging with our stakeholders, widely communicating our findings, making safety recommendations and fostering awareness of safety issues and concerns (including by issuing safety advisory notices).
The relevant transport regulatory authority, such as the Civil Aviation Safety Authority (CASA), Australian Maritime Safety Authority (AMSA), state and territory rail safety regulators, Workcover or the police may conduct investigations to determine whether there was a breach of any legislation.
Your contact with the ATSB
While the ATSB is conscious of your loss and privacy at this very difficult time, the IIC will seek to keep you informed as the investigation progresses. That communication can be with yourself or, if you would prefer, through an intermediary nominated by you.
An integral part of the communications planning is for the IIC to advise you of the pending release of the investigation report. As well, you can expect to be offered a brief by the IIC prior to the release of the final report. The aim of this briefing is to explain the investigation and findings, and to attempt to answer any questions you may have.
If you would like a briefing, please be aware that although it provides an opportunity to understand the circumstances of the accident, it may also be upsetting and you might consider having somebody available for support.
If you have any specific questions at any time, please contact the IIC on the number or email they have provided you. For any general enquiries, you can call 1800 020 616 during business hours or send us an email.