Waypoint 2007 – Investigation and data issues

Kym BillsExecutive Director ATSB30 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 fine-tuned) 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 Road Rail Marine Aviation1997 1767 68 46 371998 1755 59 46 551999 1764 47 51 462000 1817 46 42 432001 1737 56 59 422002 1715 59 48 342003 1621 48 41 442004 1583 47 41 332005 1627 38 39 432006 1599 40 na 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:

0

50

100

150

200

250

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Fatal Accidents

Non-fatal Accidents

All Accidents

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

SIIMS

Notifications & Data Entry

Investigation Team A

Investigation Team B

Investigation Team C

Safety outputs

ManualOccurrence reports

Research &Analysis

OccurrenceRecords

Occurrence reports

Safety Investigationinformation

Aviation IndustryOperatorsRegulators

OwnersManufacturers

ATSB Safety Investigation Context

Investigation Resource Management information

Management

ElectronicOccurrence reports

Public

Safety Information

Safety Information

aviation occurrences

Evidence

Evidence Information

Communicate Safety

RecordOccurrences

Investigate&

Analyse

InvestigationProject Management

information

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

Collision with Terrain

11 km NW Lockhart River Aerodrome

7 May 2005, RPT 2 crew/13 pax fatalities

VH-TFU, SA227-DC (Metro)

Safety Investigation

200501977

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).

Individual Actions

Local Conditions

Risk Controls

Organisational Influences

Transair chief pilot commitment

to safety

Transair organisational

structure

Descent problems not

corrected

Descent below segment minimum

safe altitude

Controlled flight into terrain

Loss of situational awareness

Common practices of pilot

in commandHigh workload

Pilot trainingPilot checking

Conducting RNAV (GNSS) approach when

copilot not endorsed

Descent speeds, approach speeds and rate of descent

exceeded

Transair risk management

processes

CRM conditionsCopilot ability for the RNAV (GNSS)

approaches

Crew endorsements and clearance

to line

Supervision of flight operations

Operations manual SOPs

for approaches

Operations manual

useability

Approach chart design issues

Cockpit layout

RNAV approach waypoint

names

CASA guidelines for inspectors

CASA processes for accepting approaches

Consistency with CASA oversight

requirements

CASA processes for evaluating

operations manual

Regulatory requirements

TAWS not fitted

GPWS on normal

approaches

CASA AOC approval

processes

Runway 12 RNAV (GNSS)

approach design

Regulatory Oversight CASA airline

risk profiles

Collision with Terrain11 km NW Lockhart River Aerodrome

7 May 2005VH-TFU, SA227-DC

Individual Actions

Descent problems not

corrected

Descent below segment minimum

safe altitude

Controlled flight into terrain

Conducting RNAV (GNSS) approach when

copilot not endorsed

Descent speeds, approach speeds and rate of descent

exceeded

Collision with Terrain11 km NW Lockhart River Aerodrome

7 May 2005VH-TFU, SA227-DC

The ‘acci-map’ diagram is built from the bottom up

Individual Actions

Local Conditions

Risk Controls

Organisational Influences

Transair chief pilot commitment

to safety

Transair organisational

structure

Descent problems not

corrected

Descent below segment minimum

safe altitude

Controlled flight into terrain

Loss of situational awareness

Common practices of pilot

in commandHigh workload

Pilot trainingPilot checking

Conducting RNAV (GNSS) approach when

copilot not endorsed

Descent speeds, approach speeds and rate of descent

exceeded

Transair risk management

processes

CRM conditionsCopilot ability for the RNAV (GNSS)

approaches

Crew endorsements and clearance

to line

Supervision of flight operations

Operations manual SOPs

for approaches

Operations manual

useability

Approach chart design issues

Cockpit layout

RNAV approach waypoint

names

CASA guidelines for inspectors

CASA processes for accepting approaches

Consistency with CASA oversight

requirements

CASA processes for evaluating

operations manual

Regulatory requirements

TAWS not fitted

GPWS on normal

approaches

CASA AOC approval

processes

Runway 12 RNAV (GNSS)

approach design

Regulatory Oversight CASA airline

risk profiles

Collision with Terrain11 km NW Lockhart River Aerodrome

7 May 2005VH-TFU, SA227-DC

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?