ICAO Universal Safety Oversight Audit Program


October Audit Report of the Australian Transport Safety Bureau (ATSB) of Australia
(Field work conducted in Canberra, 31 May to 4 June 2004)

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 Plan, 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

Type: Research and Analysis Report
Publication date: 22 October 2004
Last update 07 April 2014
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