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.
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, 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.
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 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. 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.
A false dichotomy, mere speculation and conflating causation and correlation.
The false dichotomy is the implication that the ATSB should either issue safety recommendations or encourage proactive safety actions that address the ‘safety issues’.
Both can happen, and both should happen, in the course and conclusion of an investigation.
If the ‘target organisation’ is prepared to accept and react to a safety recommendation, it is free to do that ‘proactively’ when the ‘safety issue’ is identified earlier in the investigation. Nobody suffers if a corresponding safety recommendation is subsequently made and closed.
If a ‘target organisation’ is not going to accept and react to a safety recommendation, the ‘target organisation’ is not going to take proactive action to address the ‘safety issue’ that would have led to the recommendation. But putting the recommendation on the public record has important consequences if it is ignored or rejected.
Certainly it’s preferable that the ‘target organisation’ take action when the ‘safety issue’ is identified rather than wait for the report, if the ATSB is going to take 1000 days to produce a report. But that’s no reason to exclude safety recommendations from the report.
The speculation is that issuing a safety recommendation in itself
may not achieve any tangible safety benefit; stakeholders are
generally best placed to determine the most effective way; the latter is
likely to be more proactive and timely. Let me speculate as well:
Perhaps the prospect of a safety recommendation being made is one of the factors that
may prompt the proactive action to address the ‘safety issue’?
I am disturbed to note that the ATSB seems not to understand the difference between causation and correlation. The ATSB seems to believe that Pel-Air’s and CASA’s actions after the ditching were caused by the safety issues identified by the ATSB.
Pel-Air’s actions were caused by a very, very cold chill after a hull loss that was a coin toss away from lives lost, and the matters revealed by the CASA audit (and probably some quiet words from Pel-Air’s insurers). CASA isn’t doing anything now that it wasn’t claiming to be doing prior to the incident. The actions of Pel-Air and CASA in this case therefore provide no support to the ATSB’s approach to safety recommendations. And what if the actions of Pel-Air and CASA
don’t turn out to be “as per the safety action detailed in the report”, despite ATSB’s speculation that it is “likely” to turn out that way?
And remind me: who’s taking the proactive and effective action in relation to the adequacy of the life vests and the procedure for deployment of the life raft?