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?
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