Waypoint 2007 –
Investigation and data issues
Kym Bills
Executive Director ATSB
30 August 2007
Multi-modal
ATSB
ATSB
• I was privileged to establish the ATSB on 1
July 1999 and to help build its international
and national reputation in aviation and
marine investigation, road safety, and
increasingly rail investigation
• Process review and cultural change takes
time and since 2003 we have had solid
legislation in place (currently being finetuned) and a nationally accredited diploma
in transport safety investigation
• 115 staff across 4 modes, most in aviation.
Australian transport safety data
• As in other OECD countries, most fatalities
are on roads - crashes cost A$18b pa
Year
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Road
1767
1755
1764
1817
1737
1715
1621
1583
1627
1599
Rail
68
59
47
46
56
59
48
47
38
40
Marine
46
46
51
42
59
48
41
41
39
na
Aviation
37
55
46
43
42
34
44
33
43
41
ATSB
• Transport safety investigations are not
intended to be the means to apportion
blame or liability, in accordance with the
Transport Safety Investigation Act 2003 and
Annex 13 to the Chicago Convention
• Powers to investigate, including to compel
evidence even if incriminatory and
reports/evidence can’t be used in courts
• ATSB is part of DOTARS for administration
and funding but separate from State bodies
like Police and rail regulators, and federal
bodies like the CASA & Airservices.
SAFETY SYSTEM
• Importantly, separate investigations by
police, regulators and OHS bodies occur
consistent with a ‘just culture’ (perhaps 10%
of accidents include culpable actions)
• The ATSB’s ‘no-blame’ safety investigation
is only one part of the total safety system
• ATSB mandatory occurrence reporting and
voluntary confidential reporting, with data
analysis and research, supplements both
investigation & industry schemes (eg SMS).
Aviation safety data
• Fatal LCRPT accidents in 2000 (Whyalla)
& 2005 (Lockhart River) but most
accidents/fatals GA & trending as below:
250
Fatal Accidents
Non-fatal Accidents
200
All Accidents
150
100
50
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Aviation safety data
• We continue to see many of the same
types of fatal accident, eg:
- controlled flight into terrain
- weather (eg VFR into IFR conditions)
- fuel exhaustion/starvation
- hitting powerlines
- high risk GA behaviour (eg low passes)
• Human factors continue to dominate management lack of awareness of human
performance limitations remains an issue.
Aviation safety data
• The ATSB’s Australian Aviation Safety in
Review covers 749 accidents 2001-2005
(mostly non-fatal; 2005 last data re hours)
• 197 mechanical: 101 powerplant, 86
airframe, 10 aircraft systems accidents
• 552 operational/handling: 197 collision
type, 105 aircraft control, 74 hard landing,
34 wheels up, 32 fuel related accidents
• In terms of phase of flight, 49% approach
and landing; 21% take-off and initial climb.
Safety data and investigation
• May 2004 $6.3m Budget funding for a new
Safety Investigation Information
Management System (SIIMS) over 4 years
• On time and under budget, we expect
SIIMS to streamline electronic reporting
• Also re-coding of historical data to enable
research comparison and trend analysis
• Expect increase in incident reporting to
continue (c 8000 last FY) via safety culture
• Choice of 80 investigations pa increasingly
difficult, of which 30 are more detailed.
ATSB business context – aviation SIIMS
ATSB Safety Investigation Context
Aviation Industry
Operators
Regulators
Owners
Manufacturers
aviation
occurrences
Manual
Occurrence reports
Record
Occurrences
Electronic
Occurrence reports
Notifications &
Data Entry
Safety Information
Occurrence reports
Safety outputs
Research &
Analysis
Safety Information
Occurrence
Records
Investigation Resource
Management information
SIIMS
Investigation
Project Management
information
Safety Investigation
information
Public
Evidence Information
Management
Investigation
Team A
Communicate
Safety
Investigation Investigation
Team B
Team C
Investigate
&
Analyse
Evidence
ATSB investigation
• ATSB 500 page Lockhart River final
report released on 4 April 2007 & refined
our prior methodology & used SIIMS
• ATSB also conducted a research study
into instrument approaches
• Considered all aspects of the aviation
system which included organisational &
regulatory issues as well as aircraft/crew
• The ATSB methodology does not require
findings against each layer if not found to
be significant.
ATSB investigation analysis
Safety Investigation
200501977
Collision with Terrain
11 km NW Lockhart River Aerodrome
7 May 2005, RPT 2 crew/13 pax fatalities
VH-TFU, SA227-DC (Metro)
Lockhart River approach profile
South Pap
Accident site
Safety factors and safety issues
• ATSB investigations encourage safety
action ahead of the final report with
release of recommendations if necessary
• Safety factors are events or conditions
that increase safety risk
• Safety issues are safety factors that have
the potential to adversely affect the safety
of future operations and are not just based
on a specific individual’s behaviour – they
are safety deficiencies requiring action.
Contributing safety factors
• Defined as a safety factor that, if it hadn’t
occurred/existed … the accident would
probably not have occurred … or another
contributing safety factor would probably
not have occurred or existed
• Probably/likely >66% cf civil law test >50%
• Evidence not sufficient for some (eg CRM)
hence these are ‘other safety factors’
• Diagram shows 19 contributing safety
factors (black border) and 13 of the 21
other safety factors (purple outline).
Regulatory
Oversight
Organisational
Influences
CASA guidelines
for inspectors
Transair
organisational
structure
CASA AOC
approval
processes
Consistency with
CASA oversight
requirements
Transair chief
pilot commitment
to safety
CASA airline
risk profiles
Pilot checking
Crew
endorsements
and clearance
to line
Local
Conditions
Common
practices of pilot
in command
Supervision of
flight operations
Pilot training
Copilot ability for
the RNAV (GNSS)
approaches
Operations
manual SOPs
for approaches
Conducting RNAV
(GNSS) approach when
copilot not endorsed
CRM conditions
Cockpit layout
Collision with Terrain
11 km NW Lockhart River Aerodrome
7 May 2005
VH-TFU, SA227-DC
Descent speeds, approach
speeds and rate of descent
exceeded
RNAV
approach
waypoint
names
Approach chart
design issues
High workload
Individual
Actions
CASA processes
for accepting
approaches
Transair risk
management
processes
Operations
manual
useability
Risk
Controls
CASA processes
for evaluating
operations manual
Regulatory
requirements
TAWS not
fitted
GPWS on
normal
approaches
Runway 12
RNAV (GNSS)
approach design
Loss of
situational
awareness
Descent below
segment minimum
safe altitude
Descent
problems not
corrected
Controlled flight
into terrain
The ‘acci-map’ diagram is built from the bottom up
Individual
Actions
Conducting RNAV
(GNSS) approach when
copilot not endorsed
Collision with Terrain
11 km NW Lockhart River Aerodrome
7 May 2005
VH-TFU, SA227-DC
Descent speeds, approach
speeds and rate of descent
exceeded
Descent below
segment minimum
safe altitude
Descent
problems not
corrected
Controlled flight
into terrain
Regulatory
Oversight
Organisational
Influences
CASA guidelines
for inspectors
Transair
organisational
structure
CASA AOC
approval
processes
Consistency with
CASA oversight
requirements
Transair chief
pilot commitment
to safety
CASA airline
risk profiles
Pilot checking
Crew
endorsements
and clearance
to line
Local
Conditions
Common
practices of pilot
in command
Supervision of
flight operations
Pilot training
Copilot ability for
the RNAV (GNSS)
approaches
Operations
manual SOPs
for approaches
Conducting RNAV
(GNSS) approach when
copilot not endorsed
CRM conditions
Cockpit layout
Collision with Terrain
11 km NW Lockhart River Aerodrome
7 May 2005
VH-TFU, SA227-DC
Descent speeds, approach
speeds and rate of descent
exceeded
RNAV
approach
waypoint
names
Approach chart
design issues
High workload
Individual
Actions
CASA processes
for accepting
approaches
Transair risk
management
processes
Operations
manual
useability
Risk
Controls
CASA processes
for evaluating
operations manual
Regulatory
requirements
TAWS not
fitted
GPWS on
normal
approaches
Runway 12
RNAV (GNSS)
approach design
Loss of
situational
awareness
Descent below
segment minimum
safe altitude
Descent
problems not
corrected
Controlled flight
into terrain
Issues and challenges
• Using all available means to avoid a major
accident is a primary challenge
• This includes good safety management
systems (SMS) among all key players
• Understanding of the limits to human
performance and organisational behaviour
• Risk analysis, threat & error management
• Helped by excellence in regulation, ATS ...
• Learning from others, mindfulness of past
lessons
Issues and challenges
• Striking the right balance between
protecting safety data and legal systems
• Getting the balance right between no-blame
and culpability in a ‘just culture’
• Trade-off between investigation timeliness
and thoroughness (eg with media and
societal expectations - instant gratification)
• The growing safety/security interface
• Using tools/data like LOSA, FOQA etc and
perhaps increasing commercial expertise
• Reinforcing appropriate independence.
Conclusion
• Australia has a very safe transport system
in international terms across all sectors
• However, major accidents are low
probability, high consequence events and
we can never afford to be complacent
• Systemic investigations remain crucial but
pro-active reporting and data analysis also
provide for evidence-based risk reduction
• The ATSB will continue to work
cooperatively with stakeholders to advance
safety while maintaining necessary
investigative independence.
Thank you
Questions?