From ATSB supplementary submission 2[1]:
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.
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. However, experience has been that this is rarely required.
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 1 00% 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.