Recommendation 4 goes to the ‘paper trail’ and transparency in the ATSB accident/incident investigation process and production of ‘Final Reports’. After all what should a, supposedly independent, Transport Safety Investigator have to hide??
4.The committee recommends that the ATSB be required to document investigative avenues that were explored and then discarded, providing detailed explanations as to why.
Such a measure would certainly have aided the committees deliberations: “The committee is concerned by the fact that no paper trail exists clearly documenting the ATSB’s decision to downgrade the issue [to a "minor safety issue"] should a similar accident a care in the future, this fact will surely be seen as a missed opportunity to enhance safety. The reasoning behind the downgrade, and the process and evidence leading to it, appears at the least unclear.”
The committee said it had considered a number of ways to encourage improvements in the conduct of safety investigations and production of reports, and foreshadows close scrutiny of issues that are causing daily increasing industry concern: “These resolve around the remit of the agency, the expertise of its leaders and quality control of its product.”
R5&R6 covers the effects of the ATSB becoming a ‘multi-modal’ investigator and addressing the resultant shortfall in necessary expertise and investigator skills by benchmarking and training with international counterparts:
5.The committee recommends that the training offered by the ATSB across all investigator skills sets be benchmarked against other agencies by an independent body by, for example, inviting the NTSB or commissioning an industry body to conduct such a benchmarking exercise.
An aspect that attracted the committee’s scrutiny was the history of the ATSB’s formation with civil aviation as just one element of a multi-modal investigator that also covers the maritime and rail environments – an aspect that may have diluted the level of aviation expertise as air safety experts transferred from the regulator to the newly established ATSB. The committee comments: “to address these shortcomings, the committee was told that the theoretical internal investigator courses the ATSB conducts simply cannot replace technical experience, and should be supplemented with training offered by the NTSB [USA] and AAIB [UK]. The committee supports this view.”
6.The committee recommends that as far as available resources allow, ATSB investigators be given access to training provided by the agency’s international counterparts. When this does not occur, resultant gaps in training competence must be advised to the Minister and the Parliament.
Interaction with international counterparts has always been a popular concept at the workface both in regulation and accident investigation. The notion of learning from other agencies however has not been embraced to the same degree, and in some cases has been scornfully rejected. A senior NZCAA official once recounted to us that when both New Zealand and Australia were setting out on the path to regulatory reform and New Zealand was already leading by a couple of laps, the offer was made to the Australian regulator to sell us the entire NZ program on a floppy disk for $1 million. It is some time since the ongoing programme in Australia has been costed, but it must by now be close to $˝ billion.
004 jumping the gun there a little bit
...oh well here is R7 :
7.The committee recommends that The Transport Safety Investigation Act 2003 be amended to require that the chief commissioner of the ATSB be able to demonstrate extensive aviation safety expertise and experience as a prerequisite for the selection process.
Which was also covered by a PAIN 'birdsong' plus a 'link'....