October Audit Report of the Australian Transport Safety
Bureau (ATSB) of Australia

(Field work conducted in Canberra, 31 May to 4 June

Executive Summary

The ICAO audit team commended the positive and professional
approach of the ATSB in proactively seeking the audit. The team was
highly satisfied with the legislative and organizational framework
established by Australia and the ATSB enabling the conduct of
aircraft accident and incident investigations. Nevertheless, the
audit focussed on all areas related to accident and incident
investigation and found possible areas of improvement.

The Transport Safety Investigation Act 2003 (TSI Act)
is the legislative framework for transport safety investigations in
aviation, marine and the interstate rail system. The TSI
Regulations 2003
, giving effect to the TSI Act, came into
force at the same time as the TSI Act on 1 July 2003. Together, the
TSI Act and the TSI Regulations comply with Annex 13 requirements
and have the necessary provisions to enable the ATSB to effectively
conduct or participate in aircraft accident and incident
investigations. The ATSB has notified its differences to ICAO in
respect of Annex 13. While section 17 of the TSI Act automatically
endorses any amendments to ICAO SARPs and gives them the force of
Australian law, the ATSB has not yet formalized its process for
reviewing the SARPs and identifying its differences.

The ATSB has its headquarters in Canberra and two regional
offices (in Brisbane and Perth). The ATSB is adequately organized
and supported by appropriate technical and non-technical staff.
However, the ATSB has not established a process for determining
staff requirements needed to adequately complete all tasks in its
area of responsibility. When establishing its Business
, the ATSB took into consideration the Departments
Portfolio Budget Statements; however, the ATSB developed the
performance indicators of its business plan based on the budget
allotted to it. As a result, the number of smaller investigations
and the scope of more complex investigations change depending on
the availability of financial resources. Ideally, the number of
accidents, serious incidents and associated safety issues should be
used as a basis for the determination of the budget. Finally, the
ATSB has not put in place a system for the control and integration
of the regional offices into the functionality and organizational
structure of the Canberra office. The ASTB has signed several
Memorandums of Understanding (MOUs) with other organizations and
authorities but some important MOUs have yet to be finalized.

The ATSB is commended for having developed a very comprehensive
training policy and programme, which includes a diploma course
entitled Transport Safety Investigation (TSI) Diploma Course. The
ATSB training policy requires all personnel who joined the ATSB
after 1 January 2000 to complete the TSI Diploma Course.
Investigators who have taken or are currently taking this course
maintain structured training files in accordance to the training
programme followed. However, not all investigators have undergone
the TSI Diploma Course. As a result, some investigators are not
part of the formal diploma programme and do not maintain a
documented record of all the types of training and briefings that
they have been provided with.

The ATSB provides its staff with all the necessary facilities
and equipment. However, the review of some of the equipment to be
used by investigators revealed shortcomings in serviceability and
record keeping. The ATSB has developed a new Safety
Investigation Policy and Procedures Manual
but has not yet
formally approved it. The procedures established by the ATSB for
the notification, investigation and reporting of aircraft accidents
and incidents, found in several manuals, are comprehensive and in
conformity with Annex 13 requirements. The ATSB focuses primarily
on fare-paying passengers and on fatal accidents (unless they
involve sport aviation), therefore some accidents that are
considered to have little potential benefit for the prevention of
re-occurrences may not be investigated in detail. In such cases,
the ATSB does not necessarily attend the scene, conduct an in-depth
investigation or produce an extensive report. Autopsy reports are
obtained by the ATSB but are not always complete. By Australian
legislation, medical examination and toxicological testing of
surviving flight crew and aviation personnel cannot be performed
after an accident.

Safety recommendations are issued by the ATSB in conformity with
Annex 13 requirements. ADREP Preliminary Reports and Data Reports
sent by the ATSB to ICAO were incomplete, partly due to the
differences in the taxonomy format. Since the ATSB is in the
process of acquiring a new accident and incident data reporting
system, it is recommended that the new database system be
ADREP-ECCAIRS compatible in order to facilitate reporting and
international exchange of data. Between 1988 and February 2004, the
ATSB managed a voluntary incident reporting system named
Confidential Aviation Incident Reporting (CAIR). A new voluntary
non-punitive incident reporting scheme, entitled Aviation
Self-Reporting Scheme (ASRS), replaced the CAIR on 21 February 2004
but has not yet been broadened to receive CAIR reports, pending
further legislative measures. In addition to accident and incident
investigation, the ATSB undertakes safety data analysis and
research. All the ATSB reports, safety recommendations and key
safety information are available on the ATSB website.

Updated January 2008

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