Error Management Training - Defining best practice

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Error Management Training- Interview study to identify error management practices in experienced training captains

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Error Management Training - Simulator study to identify error management training in current practice

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The ATSB Annual Review documents ATSB's achievements and safety activities from 1 July 2003 to 30 June 2004 and outlines its business planning for 2004-2005.

Executive Director's message

The ATSB had a busy and productive year in 2003-04 in all modes.

In its aviation activities, the ATSB released 63 investigation reports including important reports on fatal accidents at Hamilton Island, Bankstown, Moorabbin and Toowoomba and on a Saab 340 serious icing incident near Bathurst. The Bureau generated 46 air safety recommendations including those arising from the Hamilton Island investigation, on Robinson helicopter blades, and concerning the National Airspace System following a close proximity serious incident near Launceston.

The ATSB marine unit released 17 reports including on the Doric Chariot and the Star Sea Bridge accidents and also completed two reports on Sydney ferry accidents. ATSB rail outputs included an important investigation report into the Spencer Street, Melbourne 'runaway' train accident and into a level crossing accident at Aloomba in Queensland. The ATSB's twenty two 2003-04 road safety research and statistical reports included important reports on vehicle conspicuity and rural speed.

Using new 2003-04 Budget funding, the ATSB prepared and released 10 aviation research and analysis reports, developed a new rail safety investigation database (RIASIS) on time and under budget, initiated five new rail investigations on the Defined Interstate Rail Network, and established a new marine non-mandatory confidential safety reporting scheme.

During 2003-04, the Transport Safety Investigation Act 2003 (TSI Act) and Regulations applied to all new ATSB investigations in aviation, marine and interstate rail modes. Gratifyingly, there were no major problems encountered with the new legislation.

The ATSB continued to release all of its significant safety outputs to the public and hits on the ATSB website again increased to an annual rate of around eight million by the end of the financial year.

Steady progress was made with jurisdictions and stakeholders on road safety but with great challenges remaining to meet or better the 2010 target of no more than 5.6 road deaths per 100,000 population and to reduce serious injuries. A particular highlight was the release of a substantial road safety publication to mark World Health Day on 7 April 2004.

On 10 November 2003, the major ATSB aviation investigation report on maintenance problems with the Ansett Boeing 767 fleet received the Flight Safety Foundation's prestigious Cecil A. Brownlow publication award at a ceremony in Washington DC. The ATSB completed the investigation into the fatal crash of an Ilyushin IL76 aircraft near Baucau in a joint investigation on behalf of East Timor with the Australian Defence Force and in cooperation with Russian investigators. The report was released on the ATSB website after the East Timor Cabinet and senior officials had been briefed by the ATSB.

The backlog of old marine investigation reports was reduced and the number of investigations on hand at 30 June 2004 was nine compared with 19 a year earlier. Unfortunately, similar progress was not made in aviation because of other pressures and constraints, including preparation for a major audit undertaken by ICAO.

The Bureau's 2003-04 achievements, including with its additional 2003-04 Federal Budget funding for new aviation safety research, rail investigation and confidential marine reporting activities, were necessarily constrained by a 10.7 percent budget reduction applied to all groups as part of the Department's 'work out/work up' strategy. However, reflecting the Government's clear priority for the ATSB's work, the Department's Executive decided to exempt ATSB from the further round of planned Budget reductions which was required across the remainder of the Department in 2004-05. The Bureau was grateful for Federal Budget funding announced in May 2004 to ease pressures in aviation investigation and to enable replacement of the OASIS aviation safety database.

During the year the Bureau continued to liaise with and seek to improve cooperation and mutual understanding with Coroners around Australia and agreed the terms of a template memorandum of understanding (MoU) with the Coroner's representative, the Chief Magistrate of Tasmania, Mr Arnold Shott, with whom an MoU was signed in June.

A number of valued staff members retired during the year or prior to publication of this Review. I acknowledge in particular the contributions of Chris Brooks in road safety, Nick Rutherford in marine investigation and Rob Graham in leading safety investigations and work on IT systems.

I am grateful to the Deputy Prime Minister and Minister for Transport and Regional Services, the Hon. John Anderson and to the Secretary of the Department of Transport and Regional Services, Mr Ken Matthews, for their support throughout the year. It was also a pleasure working with Minister Campbell on road safety prior to his elevation to Cabinet in July 2004 and replacement by Minister Lloyd. The ATSB was again grateful for the bipartisan support it received for its safety work. The ATSB's ongoing effective role as the Australian Government's primary transport safety investigator remains reliant on both the perceptions and reality of its independence, fairness and professionalism.

Kym Bills

This project investigated the use of weather radar displays in commercial aviation. Three studies are described.

The first study used an expertise model of the use of weather radar displays to classify aircraft accident and incident reports. The three data sources used were the Federal Aviation Administration Accident/Incident Data System, the National Transportation Safety Board Accident and Incident Database, and the Aviation Safety Reporting System. Although generalisation of the outcomes is limited, the results provide some evidence to suggest that where the use of weather radar was implicated in an aircraft accident or incident, the error was most likely to be associated with a failure to recognise and/or interpret the information on the display.

Study Two involved a cognitive interview of experienced commercial pilots and their use of weather radar displays to assist in the management of flight. The results revealed a relatively consistent response which emphasised the timely and accurate interpretation of radar 'paints' as the basis for successful performance. It was apparent that, for some pilots, the process involved the development and application of 'rules-of-thumb' and that these rules had been acquired through experience.

The results of Studies One and Two provided the basis for the development of a survey that was distributed to pilots both in hard-copy and on-line via the internet. Respondents were asked to provide information about their use of weather radar displays, describe an incident involving the use or misuse of weather radar displays, and give their interpretations of a series of 12 simulated weather radar 'paints'. In the case of the incidents described by the respondents, the results indicated that the majority of cases were related to the recognition and interpretation of the information on displays, consistent with the outcomes of Study One.

In relation to the simulated weather radar 'paints', the results indicated that while the interpretation of some of the displays was relatively consistent, the responses to other displays were less consistent between respondents. These differences were not due to demographic features such as age or experience but appeared due to the level of ambiguity associated with the displays. Specifically, for some displays, it appeared that the key cues necessary for the successful interpretation of the information were either difficult to interpret or were absent. This outcome forms the basis for a number of recommendations concerning improvements in training, education and the design of weather radar displays.

During 2004 the Neville Committee conducted an Inquiry into Train Illumination.

The Committee tabled its report, Train Illumination: An inquiry into some measures proposed to improve train visibility and reduce level crossing accidents, on 24 June 2004.

The report can be downloaded from the Neville Committee's website: Train Illumination: An inquiry into some measures proposed to improve train visibility and reduce level crossing accidents(Opens in a new tab/window) can be downloaded from the Neville Committee's website.

The Government Response to the report, which was coordinated by the Australian Transport Safety Bureau, was tabled in Parliament on 7 December 2005 and is available below.

This report presents data concerning Australian aviation activity, the aviation industry, aviation accidents and incidents and highlights broad trends and developments in aviation safety. The data are presented graphically in time series figures. Data on aviation accidents and incidents were collected from the ATSB's aviation database. Data concerning aviation activity, the aviation industry, accidents and specific incident types were collected from three main sources: the Bureau of Transport and Regional Economics, part of the Department of Transport and Regional Services, the Civil Aviation Safety Authority and Airservices Australia.

The aim of this study was to provide information to the flying community about issues that have the potential to affect safety in the hope that increased knowledge and insight could lead to improved safety. The ATSB distributed the 'Aviation Industry Safety Survey' in November 2003 to 5,000 commercial pilots throughout Australia. Pilots were asked to respond to a series of questions regarding their flying experiences in the 12 months prior to receiving the survey. The survey consisted of two sections: Part A and Part B. Information about Part A has been reported in the ATSB Aviation Safety Survey - Safety Climate Factors (2004) publication. The analysis of one question (relating to common flying errors by respondents) in Part B was reported in the ATSB Aviation Safety Survey - Common Flying Errors (2004) publication. This report addressed six questions (39 to 44) in Part B of the survey (reproduced in Attachment A). Information concerning pilot age, highest licence held, hours flown, type of operation and aircraft details were obtained from the survey responses.

The twin-engine power loss accidents were analysed to identify the types of accidents that occurred. Ten of the 11 fatal accidents subsequent to a power loss in twin-engine aircraft were the result of an in-flight loss of control. In contrast, the majority of non-fatal accidents subsequent to a power loss were primarily the result of degraded aircraft performance and resulted in aircraft being forced landed. When a twin-engine aircraft sustains a loss of power, the resulting power output can produce a power condition that is either asymmetric or non-asymmetric. The twin-engine power loss accidents were grouped based on whether the aircraft was being powered asymmetrically or non-asymmetrically when the accident occurred.

Weather-related general aviation accidents remain one of the most significant causes for concern in aviation safety. Previous studies into the factors associated with weather-related general aviation occurrences have typically compared accident and non-accident cases. In contrast, this study does not concentrate on occurrence outcome. Instead, the emphasis is on the different behaviours that pilots exhibit in the face of adverse weather and, by inference, on the decision-making processes that underlie those behaviours. The work of this study is based on a set of 491 aviation accident and incident reports drawn from the Australian Transport Safety Bureau (ATSB) occurrence database. The study compares three groups of pilots who differed in their response to adverse weather conditions encountered during their flight.

Night Vision Goggles (NVGs) are binocular devices that enhance unaided night vision for pilots. Typically, NVGs are mounted on a pilot's helmet. This position enables pilots to look through the goggles outside the cockpit or under the goggles at flight instruments. By enabling the pilot to see in the dark, NVGs have the potential to improve the safety of visual flight at night. In most conditions, night vision goggles provide pilots with a significant increase in the quality of visual information compared with unaided night vision. They allow the pilot to see the horizon, objects, terrain and weather more easily. Furthermore, they assist the pilot to maintain spatial orientation, to avoid hazards such as inadvertent Instrument Meteorological Conditions (IMC) entry, and to visually navigate.

The determination of blood ethanol concentration in a deceased pilot is an important part of the accident investigation. The finding of an elevated blood alcohol level in such a case may have significant implications, both medico-legal and social. It is therefore important to ensure that the finding of an elevated blood alcohol concentration is valid.

It is known that micro-organisms involved in the process of putrefaction after death can produce alcohol, usually a mixture of ethanol and other volatile substances. This process occurs when a body is not refrigerated soon after death and is hastened by environmental conditions such as high temperatures and when the body has been traumatised.

Older methods of analysis could not distinguish between ethanol and mixtures of other volatile compounds. Current methodology (gas chromatography) can isolate ethanol and identify other substances.

There is a range of specimens in which ethanol can be measured. Their suitability for analysis can be determined by microbiological studies although this would not be routinely performed in most laboratories.

Medico-legal and forensic implications are associated with a 'blood alcohol concentration'.49 It therefore seems most useful to measure the ethanol level in a specimen of blood, but this may not always be available depending on the state of the body. Vitreous is the next specimen of choice, and valid conclusions regarding the ingestion of alcohol can usually be made based on the results of its analysis.

Urine analysis may also be helpful, particularly in conjunction with blood and vitreous. Comparison of levels of these three specimens is probably the ideal means of interpreting blood alcohol concentrations. If none of these specimens is available, resort can be made to other organ and tissue samples but there are difficulties in both methodology and interpretation of results relating any alcohol present to ingested ethanol.

Ethanol in gastric contents generally indicates recent ingestion, but the rapid absorption of ethanol and post-mortem diffusion from the stomach may limit the usefulness of analysis of gastric contents.

The presence of volatile compounds in addition to ethanol (seen by gas chromatography methods) may suggest post-mortem production by micro-organisms but also needs to be interpreted cautiously.

It is possible to measure parameters which are associated with or indicate ethanol consumption. These are qualitative only and do not enable the blood ethanol concentration to be calculated or estimated. They have applications in a clinical setting where they address the issue of alcohol consumption in previous days. This is not usually the main issue in a fatal aviation accident investigation, where the "bottle to throttle" rule applies, and the issue is what factors were influencing the pilot's capacity to fly the aircraft. Two of these measurements, ethyl glucuronide and the 5-HTOL: 5-HIAA may have some application in the future of fatal aviation accident investigation, but they are not currently performed routinely.