ATSB fatality investigations in Australia and the Asia Pacific

Kym BillsExecutive Director ATSBAsia-Pacific Coroners’ Conference31 October 2007

Overview• I am grateful for the opportunity to be here• I will give a short overview of the ATSB• Provide some context on transport fatalities• Indicate how and why the ATSB seeks to

prioritise limited investigation resources• Outline our recent Asia Pacific involvement• Introduce the methodology used in larger

investigations such as Lockhart River, and• Note issues with legal concepts and the

desirability of further Coroners’ dialogue.

Multi-modal ATSB

ATSB• Multi-modal body to investigate, analyse and

report independently on aviation, interstate rail & major marine safety occurrences

• Transport safety investigations are not intended to be the means to apportion blame or liability, in accordance with the Transport Safety Investigation Act 2003 (TSI Act) & Annex 13 to the Chicago Convention

• Powers to investigate, including to search and compel evidence even if incriminatory

• But reports/evidence can’t be used in courts with the exception of Coronial inquests.

• The ATSB is part of the Australian Government Department of Transport and Regional Services (DOTARS) for administrative and resourcing purposes

• Separate from State bodies like Police and rail regulators, and federal bodies like the Civil Aviation Safety Authority (CASA) & the Australian Rail Track Corporation (ARTC)

• Importantly, separate investigations by police, regulators and OHS bodies occur consistent with a ‘just culture’ (perhaps 10% of accidents via a form of culpable actions).

• Hence, the ATSB’s no-blame safety investigation is only one part of the system

• To reinforce independence, under the TSI Act S15, neither the Minister nor Secretary are to influence ATSB investigations

• ATSB mandatory occurrence reporting, voluntary confidential reporting and data analysis and research supplement both investigation & industry schemes, eg SMS

• Approx 115 ATSB staff, most in Canberra and three quarters aviation-related including notifications, administration etc- annual budget now almost $20 million.

Australian transport safety data• The overall transport accident death rate

across road, rail, marine and aviation decreased from 10.4 deaths per 100,000 population in 1997 to 8.3 in 2006:

7

8

9

10

11

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Dea

ths

per

100

000

peop

le

Australian transport safety data• As in other OECD countries, most

fatalities are on roads– overall crash cost A$18b paYear Road Rail Marine Aviation

1997 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

Road safety fatality data• Major factors remain speed, alcohol/drugs,

fatigue, distraction, vehicle design and safety features, road design and features

• Most deaths occur among car drivers and passengers and disproportionately among young post-P plate drivers

• Motorcyclist fatalities up 22% since 2004 and growing among over-40 males but most deaths still young males

• About 30,000 serious injuries on our roads annually (via hospitalisation), c2/3 males.

Road safety data

• ATC National Road Safety Action Plan for 2007 & 2008 coordinated by the ATSB includes many cost-effective measures:- that have not been implemented, or- have not been implemented in all jurisdictions, or- have not been implemented on a sufficient scale

• eg Victoria’s tough speed campaign:

Victorian campaign on speeding:

Rolling 12 month average

5

6

7

8

9

10

11

Dec-98 Dec-00 Dec-02 Dec-04 Dec-06 Dec-08

Dea

th ra

te p

er 1

00 0

00 p

opul

atio

n

Victoria

Australia (excluding Victoria)

Victorian road deaths fell by 31% in the two years

to April 2004

Marine safety data

• Mostly via recreational boating there are about 40 marine fatalities annually

• The ATSB mainly investigates large ships (also Cwth vessels like Malu Sara) and the almost 250 investigations since 1991 include 34 fatal accidents, 64 groundings, 41 collisions, and 28 fires/explosions

• A number of fatalities involved lifeboat drills and collisions with fishing vessels

• ATSB key role at the IMO in improving investigation requirements/standards.

Rail safety data

• ATSB has been working with state and NT rail regulators since 1999 to obtain and publish nationally comparable safety data

• After many false dawns, in June 2007 we published regulator data covering calendar 2001 to 2006 inclusive

• This is a basis to build from via National Transport Commission (NTC) and the Australasian Railway Association (ARA).

Rail safety data• National regulator data for calendar 2006

include:- 40 ‘non-suicide’ deaths- 127 serious injuries (excluding NSW)- 120 running line derailments- 191 running line collisions (105 with infrastructure, 46 with persons, 16 road vehicles, 14 rollingstock, 10 other trains)- 92 level crossing collisions (82 with road vehicles, 10 with persons)- 414 serious ‘signals passed at danger’.

Rail safety investigations

• ATSB investigation reports have led to significant safety action in the areas of medical standards, vigilance devices/pilot valves, the need for better/standardised communications, human error-tolerant systems, and level crossing risk-based treatments and broader education

• There remain a number of serious level crossing accident investigations underway

Aviation safety data• Fatal LCRPT accidents in 2000 (Whyalla)

& 2005 (Lockhart River) but most accidents/fatalities GA (non-sport) shown:

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)

• In aviation & other modes human factors continue to dominate - management lack of awareness of human performance limits and structures remains an issue.

Some key ATSB references

• ATSB website has: an interactive road safety database and monthly analysis; initial rail safety data for 2001-2006; aviation data updated monthly; basic marine data in the ATSB Annual Review

• ATSB research reports for road & aviation: eg Digest of all ATSB research for 2006; HFACS comparison with US; initial Australian Aviation Safety in Review

• (n.b. we use Coronial database especially in road and road/rail safety research.)

Investigation prioritisation

• In aviation we received over 13,000 event reports last FY of which almost 8,000 were classified as accidents (112) or incidents

• Resourced for 80 investigations (30 larger)• Required under Chicago Convention to

investigate international carrier accidents• Annex 13 standard re all accidents and

recommended practice re serious incidents• Do non-sport fatals to assist Coroners but

often most safety value in selected RPT incidents so very tough judgements/choices

Asia Pacific role• We regularly assist the NZ TAIC and the

ADF especially with aviation investigations• Resources are tight and eg PNG has no

legislation and there are sensitivities re Fiji• PASO regulation may lead to investigation• Helped Taiwan ASC set up recorder lab &

do read-outs when requested• Teach in region - Singapore, Hong Kong• Investigations include QF1, SQ006, IL76:

QF1 747-400 Bangkok

SQ006 747-400, Taipei

IL76 CFIT Bacau, East Timor

IL76 CFIT Bacau, East Timor

Indonesia safety cooperation

• The ATSB has a longstanding relationship with Indonesian counterparts (NTSC) and had arranged last year a pilot placement

• Garuda 7 March 2007 accident we assisted on site and with recorders - major report drafting assistance et al

• Ongoing cooperation re Adam Air 1/1/07 and marine investigations, plus training in investigation, HF etc

Garuda 737-400, Yogyakarta

Based on professionalism and sound methodology this is what we seek to avoid!

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 Investigation

Large team of investigators:• Examined aircraft components - on-site and

in laboratory• Examined cockpit voice recorder and flight

data recorder and radio recordings• Hindered by lack of usable cockpit voice

recorder information, level of damage to aircraft, and no survivors or witnesses

• Assisted by flight data recorder, 25,000 pages of evidence, over 100 interviews

Lockhart River investigation

• Considered all aspects of the aviation system which included organisational & regulatory issues as well as aircraft/crew

• Conducted a research study into instrument approaches

• 500 page final report released on 4 April 2007 used ATSB Safety Investigation Information Management System (SIIMS)

• May 2004 $6.1m Australian Government Budget funding for SIIMS over 4 years.

Controlled flight into terrain (CFIT)

• Pilots lost situational awareness in cloud during a type of GPS-linked approach & made no discernable attempt to pull up

• No evidence of– problems with flight controls– problems with engines or propellers– pilot incapacitation– windshear etc.

Lockhart River approach profile

South Pap

Accident site

Risk Controls (Recovery)

Risk Controls (Recovery)

Risk Controls(Preventive)

Local Conditions

Individual Actions

Technical Events

Production Goals

Accident

Organisational Influences

Incident

ATSB investigation analysis model

ATSB investigation analysis model

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

• Evidence not sufficient for some (eg CRM) with ‘probably’ defined as >66% (c. 2 in 3)

• ‘Acci-map’ diagram shows 19 contributing safety factors (black border) and 13 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 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

Lockhart River methodology

• QLD State Coroner used the ATSB Final report and research report as key evidence

• CASA suggested methodology not mature, biased towards finding regulator issues, >66% test too weak etc

• No direct influence on cockpit• Coroner raised other methodology issues

re 66% being too precise or mechanistic & the desirability of a ‘Briginshaw’ type test, ie tougher on evidence if grave consequences

Methodology paper

• ATSB had been criticised in the Whyalla inquest that not precise enough re probability terminology, and methodology

• Double engine failure sequence: did use judgment as well as statistical probabilities

• While judgement also used in assessing the >66% (cf US ‘clear & convincing’) and probably/likely terminology is supported by International Panel on Climate Change, I have commissioned a paper on the issues

Methodology paper• Perhaps Coroners’ end-focus on fatalities

(>50% causality) & safety issues additional cf ATSB focus at each link (>66%) via broad view of causality & safety issues regardless of contribution may occasion differences

• Issues in legal writing & case law regarding use of probabilities and Briginshaw

• McHugh J (1995) “I know Briginshaw is cited like it was some ritual incantation. It has never impressed me too much. I mean, it really means no more than, ‘Oh, we had better look at this a bit more closely than we might otherwise’, but it is still a balance of probabilities in the end.”

Methodology paper• Anderson et al (CUP 2005) “Until recently

most legal scholars have accepted the view that evaluation of evidence can rarely be governed by rules. … The so-called ‘probability debates’ in law have been underway now for over thirty years.”

• Freckleton et al note pressures at inquests by parties seeking to prepare for other litigation can make them adversarial etc

• Hopkins: focus varies based on self-interest• My aim is that a draft paper initially be sent

to State Coroners for comments

Growing challenges

• Striking the right balance between protecting safety data and regulatory and legal systems

• Getting the balance right between no-blame and culpability in a ‘just culture’

• Professionalism and robust methodology• What trade-off should there be between

investigation timeliness and thoroughness (eg with media and societal expectations)

• The growing safety/security interface

Continuing challenges

• Using all available means to avoid a major accident is a primary challenge

• This includes good safety management systems among all key players

• Understanding of the limits to human performance and organisational behaviour

• Risk analysis, threat & error management• Helping foster safety cooperation and

excellence in regulation• Learning from others, mindfulness of past

lessons, & never taking safety for granted:

SAFETY MANAGEMENTAND THE SINKING OF BRAZIL’S LARGEST OFFSHOREOIL PLATFORM

March 2001COURTESY OF: PAT HUMISTON & GEOFF DELL

A lesson against hubris & for those involved in cutting project management costs

The following quote is from one of the company’s financial executives extolling the benefits of cutting safety management, quality assurance & inspection costs

on the P36 project that sunk into the Atlantic Ocean off the coast of Brazil in March 2001

“The Company has established new global benchmarks for the generation of exceptional shareholder wealth”

“through an aggressive and innovative program of cost cutting on its P36 production facility.”

“Conventional constraints have been successfully challenged”

“and replaced with new paradigms appropriate to the globalised corporate market place.”

“Through an integrated network of facilitated workshops”

“the project successfully rejected the established constricting and negative influences of prescriptive engineering onerous quality requirements, and outdated concepts of inspection and client control ”

“Elimination of these unnecessary straightjackets has empowered the project's suppliers and contractors to propose highly economical solutions”

“with the win-win bonus of enhanced profitability margins for themselves.”

“The P36 platform shows the shape of things to come...”

“in the unregulated global market economy of the 21st Century”

Humility, mindfulness and common sense are required for future safety & willingness

to learn from history & each other

Thank you

Questions?