This report presents a tool for representing and analysing recorded voice data in investigations of aviation occurrences, or other transport occurrences. The report is one part of a research consultancy project conducted by the author for the Australian Transport Safety Bureau (ATSB). The two project outcomes are the result of around one month's full-time activity, conducted over March to June 2006.

The overall aim of the project is to explore the potential value of an established sociological academic research methodology, called conversation analysis (often CA), for representing and analysing recorded voice data for investigations of aviation or other transport occurrences. The project can expand the level of understanding that investigators can obtain from a voice recording as part of an investigation. Conversation analysis may be especially valuable for investigating transport occurrences because it focuses on examining the details of communication in context, as it actually occurs in real time.

The project has two parts. The first part is a series of sample transcriptions and analyses of recorded voice data from five occurrences previously investigated by the ATSB or BASI. The second part is this report, and is a tool for using conversation analysis to inform and guide analysis of recorded voice data in investigations.

Significant attention has been given in the literature to aviation safety, with emphasis on the importance of developing and maintaining resilience to accidents.  To date, this attention has remained at the conceptual level, with comparatively little empirical research undertaken to test the validity of concepts put forward in the literature. This report presents the findings of a qualitative study, investigating the factors perceived to facilitate safety culture and institutional resilience within airlines.  Thirty-two senior managers, drawn from Safety Departments and Flight Operations Divisions, participated in the research, representing 12 airlines operating in the Asian and Pacific regions.  Data was obtained through semi-structured interviews with participants, based on questions relating to terms contained in James Reason's Checklist for Assessing Institutional Resilience.

The checklist provided a useful framework for obtaining data; however, some terms reflected exclusivity in identifying factors that impact on organisational resilience, and others significantly overlapped in their application to the airline industry.  Themes emerging from the findings include the importance of leadership roles undertaken by the board, senior management, chief pilots and safety departments, and the influence of both formal and informal performance management systems.  Analysis of the findings addresses the implications for Reason's checklist, and identifies those factors that are not on the checklist but perhaps ought to be.  The emergence of a model which may be empirically tested through quantitative design is considered, along with other recommendations for future research.  In conclusion, strategies are presented, drawn from the data, which support the presence or absence of safety cultures within the airline industry and impact on ability to assess institutional resilience.

Civil aviation safety is based on managing the safety of knowledge of things that can affect the safety of flight. One of these sets of knowledge is confidence that the facilities at the destination will be good enough to give confidence of a safe landing. Weather at the destination can affect the safety of a landing. Detailed historical records are kept of weather observations and weather forecasts. This study has analysed the level of statistical confidence that has been achieved with destination weather forecasts under various conditions. It has also looked at other mechanisms that are or could be used to reduce the risk in addition to the existing methods.

On the 20th May 1988 at approximately 1609 hours, a Cessna 172 collided with a Piper Tomahawk in the circuit area at Coolangatta, Queensland. The accident, in which four people died, occurred in conditions of good visibility.

This collision and others which occurred in the late 1980s drew attention to the deficiencies of the see-and-avoid concept.

The Coolangatta accident report stated that: 'As a result of this accident, the Bureau of Air Safety Investigation has undertaken to conduct an evaluation and prepare a report on the practicability of the see and be seen (see-and-avoid) principle in controlled and non-controlled airspace.' (BASI report 881/1042).

This report, prepared in response to that undertaking, summarises the research relevant to unalerted see-and-avoid and is intended as a reference document for Civil Aviation Authority (CAA), Industry, and BASI personnel as well as a source of recommendations. The report does not analyse the Australian accident experience.

This study provides an overview of aircraft cabin safety communications in Australia, in terms of effectiveness, passenger attitudes to such communications and opportunities that exist for improvement.

Most passengers agreed that paying attention to cabin safety communications is important. However, results revealed that behaviours do not always match this perception. Perceived relevance of safety information and frequency of travel were found to be significant factors affecting passenger attitudes and behaviours. High levels of message recognition, combined with excessive levels of confidence in personal ability to perform safety actions may be key drivers of reduced perceptions of relevance.

Passenger attention levels to safety communications were found to be generally low. Of all communication types tested, the safety briefing was most prone to perceptions of reduced relevance through repeated exposure, while very low attention levels and perceptions of content establish safety cards as being generally ineffective.

Analysis identified that low levels of passenger attention to safety communications results from overconfidence, superficial familiarity with messages, issues relating to the way safety content is presented, perceptions of substitutability between the card and briefing and social norms present in the aircraft cabin.

A framework for cognitive processing of cabin safety communications is presented. The framework identifies that passenger behaviours may be negatively influenced by perceptions that it is socially undesirable to pay attention to safety information. Changing normative and attitudinal beliefs represents the greatest opportunity to improve communication effectiveness.

Key opportunities are identified to improve cabin safety through enhancement of communications. These recommendations include tailoring communications to the needs of specific passenger profiles, providing additional information to passengers, improved design guidelines, regular content variation and use of communications specialists in safety media design.

Executive Director's message

The 2005-06 financial year continued to have a substantial building element for the ATSB as rail investigation further matured and aviation investigators were trained and prepared for 2006-07 implementation of a new aviation safety database with associated project and risk management.

The Bureau is continuing its commitment to training its investigators through the Diploma of Transport Safety Investigation. In 2005-06, ten staff completed the Transport Safety Investigation (TSI) Diploma and a further 25 were progressing through the coursework and mentoring.

In addition to releasing 93 final aviation investigation reports, ten aviation safety research reports and eight grant reports, substantial work occurred on the fifteen-fatality Lockhart River accident investigation, including the issuing of a number of safety recommendations.

In marine, 13 investigation reports were released including a major report into the loss of the Department of Immigration and Multicultural Affairs vessel Malu Sara in Torres Strait which resulted in five fatalities. The ATSB also continued an education campaign within the fishing industry on commercial fishing vessel safety.

The ATSB's rail safety investigation team released 11 final reports under the TSI Act. In October 2005 the Queensland Minister of Transport released the final report of the joint Queensland Transport/ATSB investigation into the Tilt Train accident which occurred north of Bundaberg in November 2004, and in February 2006 the Victorian Minister for Transport released the final ATSB report on the Benalla level crossing fatal accident.

The ATSB continued to support Ministers with road safety advice and coordinated input with other jurisdictions. In 2005-06 we released 22 road safety research and statistical publications including an Indigenous Road Safety Update. Preparations were also made for a national indigenous road safety forum later in 2006.

There were two areas of particular disappointment in 2005-06. First, there was little progress on a road safety education trial for novice drivers in partnership with NSW and Victorian governments and industry bodies primarily because of finance, risk and governance issues with Victoria.

Second, rail regulators advised the ATSB that even the very basic safety data that had been provided for several years was not accurate or comparable and broader data promised under an April 2005 memorandum of understanding would be significantly delayed. Obtaining quality rail safety data from jurisdictions has been a goal of the ATSB since 1999. The ATSB provided $80,000 late in 2005-06 to rail regulators to support an audit to seek to resolve data issues and provide a basis to make real progress for the future.

On 1 March 2006 I became the Chairman of the International Transportation Safety Association (ITSA), which includes a dozen of the major independent transport safety investigation bodies from around the world. The annual ITSA meeting was held in Canberra later that month and was a very helpful forum for exchanging information and enabling learning from sharing the good (and less good) experiences of colleagues.

A number of valued staff members retired during the year or prior to publication of this Review. I wish to express my particular appreciation for the long term contribution to marine and rail safety by Captain Kit Filor PSM who has been the ATSB's Deputy Director of Surface Transport Investigation since July 1999 and previously the Inspector of Marine Accidents from January 1991. Kit has made an enormous contribution in Australia and internationally.

I am grateful to the Minister for Transport and Regional Services, the Hon. Warren Truss MP, the Minister for Local Government, Territories and Roads, the Hon. Jim Lloyd, MP, and to the Secretary of the Department of Transport and Regional Services, Mr Mike Taylor for their support throughout the year.

Area navigation global navigation satellite system (RNAV (GNSS)) approaches have been used in Australia since 1998 and have now become a common non-precision approach. Since their inception, however, there has been minimal research of pilot performance during normal operations outside of the high-capacity airline environment. Three thousand five hundred Australian pilots with an RNAV (GNSS) endorsement were mailed a questionnaire asking them to rate their perceived workload, situational awareness, chart interpretability, and safety on a number of different approach types.

Further questions asked pilots to outline the specific aspects of the RNAV (GNSS) approach that affected these assessments.

Responses were received from 748 pilots, and answers were analysed based on the aircraft performance category¹. For pilots operating Category A and Category B aircraft (predominantly single and twin-engine propeller aircraft), the RNAV (GNSS) approach resulted in the highest perceived pilot workload (mental and perceptual workload, physical workload, and time pressure), more common losses of situational awareness, and the lowest perceived safety compared with all other approaches evaluated, apart from the NDB approach. For pilots operating Category C aircraft (predominantly high-capacity jet airliners), the RNAV (GNSS) approach only presented higher perceived pilot workload and less perceived safety than the precision ILS approach and visual day approach but lower workload and higher safety than the other approaches evaluated. The different aircraft category responses were likely to have been due to high-capacity aircraft having advanced automation capabilities and operating mostly in controlled airspace. The concern most respondents had regarding the design of RNAV (GNSS) approaches was that they did not use references for distance to the missed approach point on the approach chart and cockpit displays. Other problems raised were short and irregular segment distances and multiple minimum segment altitude steps, that the RNAV (GNSS) approach chart was the most difficult chart to interpret, and that five letter long waypoint names differing only by the last letter can easily be misread.

1. Aircraft performance approach categories are determined by multiplying the aircrafts stall speed in the approach configuration by a factor of 1.3. See Section 3.1.

Producing the annual review is in line with a recommendation of the McGrath report into the former Bureau of Air Safety Investigation released in August 1999 to improve the transparency and accountability of the Bureau.

Creation of the ATSB on 1 July 1999 brought together the safety investigation, statistical analysis, research and safety program management of the Commonwealth's transport safety role in one multi-modal agency within the Department of Transport and Regional Services. ATSB intends to prepare an annual review to provide all stakeholders with an overview of its activities and safety in each transport mode. This first review covers a range of topics including:

• ATSB's safety mission, values, organisational structure, operational environment and internal management;
• key ATSB safety results by transport mode;
• a statistical overview of safety in the transport modes of road, rail, aviation and marine;
• ATSB participation in Parliamentary inquiries; and
• ATSB's performance against the measures in the 1999-2000 Portfolio Budget Statements

Transport accidents are a leading cause of injury, both fatal and non-fatal. The primary purpose of this publication is to provide a broad overview of serious injury due to transport accidents in Australia in the one-year period 2003-04, the latest year for which data are available.

Serious injury is defined for this report as an injury which results in the person being admitted to hospital, and subsequently discharged alive either on the same day or after one or more nights stay in a hospital bed (i.e. deaths are excluded). This report presents estimates of the numbers of persons seriously injured in Australia due to transport accidents in the one-year period 2003-04. All modes, air, sea, road and rail, are included.

Publication available from the Australian Institute of Health and Welfare website(Opens in a new tab/window)

Transport accidents are a leading cause of injury, both fatal and non-fatal. The primary purpose of this publication is to provide a broad overview of serious injury due to land transport accidents in Australia in the one-year period 200304, the latest year for which data are available. The main focus is on accidents involving road vehicles travelling on public roads (called travelling in traffic). Road vehicles include motor vehicles, pedal cycles and other road vehicles such as trams, animals or animal-drawn vehicles (when they travel on the road).

Serious injury is defined for this report as an injury which results in the person being admitted to hospital, and subsequently discharged alive either on the same day or after one or more nights stay in a hospital bed (i.e. deaths are excluded).

This report presents estimates of the numbers of persons seriously injured in Australia due to land transport accidents, including road traffic crashes, in the one-year period of 2003-04. Trends in injury rates in road traffic crashes are examined over a five-year period, 1999-00 to 2003-04.

Publication available from the Australian Institute of Health and Welfare website(Opens in a new tab/window)