PPRuNe Forums - View Single Post - Norfolk Island Ditching ATSB Report - ?
View Single Post
Old 3rd Dec 2012, 23:50
  #653 (permalink)  
Sarcs
 
Join Date: Apr 2007
Location: Go west young man
Posts: 1,733
Received 0 Likes on 0 Posts
ATSB sup submission 2(1) Appendix B deals with the change of philosophy/methodology of ATSB 'safety actions' and the once obligatory 'safety recommendation'.

"Managing safety issues and actions

Traditionally, accident investigation agencies produce final reports and issue safety recommendations to other organisations or individuals, to encourage change in order to prevent a recurrence of an accident.

Comment: What is wrong with tradition and a tried, accepted and justified methodology that means pertinent safety issues discovered in the course of an accident/incident investigation are disseminated and transparent to aviation stakeholders worldwide?

Further, performance targets are often associated with the number of recommendations issued by investigation authorities. The focus of an ATSB investigation is on achieving safety outcomes; that is through the identification of the factors that increased risk, particularly those associated with ongoing/future risk (safety issues), such that action can be taken by relevant organisations to address the identified 'safety issue'.

This does not in itself require the issuing of safety recommendations, although that is an option. Noting that safety recommendations are not enforceable (Perhaps they should be??), the issuing of a safety recommendation in itself may not achieve any tangible safety benefit, if the target organisation elects not to accept and react to the recommendation. Maybe the organisation shouldn't have any choice?

In this regard, the ATSB prefers to encourage proactive safety actions that address the 'safety issues' identified in its reports. Other benefits of this approach are that the stakeholders are generally best placed to determine the most effective way to address any 'safety issues' and the publication of the safety actions that address an issue proactively should be viewed as a positive step that provides for timely safety action prior to the release of the report and a level of completeness (Beaker always the 'tidy freak') when the final report is published. This approach is reflected in the difference that Australia has filed with respect to Annex 13 para 6.8.

The response to a safety recommendation is most often unlikely to be any different to the safety action reported by an organisation in response to an identified safety issue, but the latter is likely to be more proactive and timely (Based on whose assessment?). That is specifically the case with respect to the Norfolk Island investigation, where the responses to any formal safety recommendations to CASA and Pel-Air related to the two identified safety issues, are likely to be as per the safety action detailed in the report.

Reference 'Safety Actions' pages 45-49 of the ATSB report: http://www.atsb.gov.au/media/3970107...-072_Final.pdf

The ATSB is in the process of redeveloping its website to be 'safety issue' focused rather than 'recommendation' focussed. The point of importance is that the safety issue remains open (like a recommendation) until such time as it is either adequately addressed, or it is clear that the responsible organisation does not intend taking any action (and has provided its reasons). In the event that no, or limited, safety actions are taken or proposed, the ATSB has the option to issue a formal safety recommendation.

This statement does show a proactive approach to tracking and disseminating the safety action/issue information. So why then change the methodology and on what evidence/research has this new policy/approach to safety actions/issues based?

However, experience has been that this is rarely required. Would that be the experience of the last four years since Beaker took over?

The ATSB's Safety Investigation Information Management System (SliMS) provides tools for investigators to record and track safety issues and actions, including through the setting up of alerts to prompt periodic follow-up of progress with safety action where a safety issue is open and the safety actions are being monitored (the same process applies if a recommendation were issued). In addition, a standing agenda item is included in the quarterly Commission meetings to review safety issues and actions during the previous quarter, with particular focus on those that remain open.

The ATSB's Annual Plan and part of the ATSB's Key Performance Indicators
specifically relate to a measurement of safety action taken in response to safety issues; in the case of 'critical' safety issues, the target is for safety action to be taken by stakeholders 100% of the time, while for 'significant' safety issues, the target is 70%.

For the FY11 /12, there were no identified critical safety issues and 28 significant safety issues. In response to the significant safety issues, adequate safety action was taken in 89% of cases and a further 4% were assessed as partially addressed."

Definitely more questions to be asked in regards to the demise of the 'Safety Recommendation' in Oz??

The Beaker spin in this sup submission highlights that the ATSB can no longer be regarded as independent and left to carry out an essential service without fear nor favour. The ATSB is now a neutered, ineffective agency that is more interested in not upsetting various 'stakeholders'.

The 'Beaker policy' (and by default Albo's policy) is totally flawed and if allowed to continue will see the total demise and reputation of the ATSB go down the plughole. Hopefully the Senators can see these issues and are not deterred by the Beaker spin!
Sarcs is offline