ATSB reports

[Sarcs]

Bumping up the numbers or is Beancounter Beaker a genius??

To be fair to the ATSB the two (best described as desktop investigations) ****e reports under the spotlight were both part of the October edition of the short investigation bulletin (Aviation SIB – Issue 23). I should clarify I do not question the bods on the ground that they are only doing what they are told, with the allocated (limited) resources given to them. However I am very sceptical about the true motives behind the ATSBeaker short investigation process??

Maybe Old Akro has hit the nail on the head…“The backlog of unreleased reports from the ATSB is growing. There have been very few reports on significant incidents released in the last few months. I suspect they are trying to release as many "easy" reports as they can to try and meet their KPI's.”

So what exactly is the bureau methodology behind the short investigation process?? Ok if you refer to the ATSB page Terminology, investigation procedures and deciding whether to investigate and under Background it says…

“Following the initial assessment of a notification, a decision is made whether or not to conduct an investigation. Some occurrences may be subject to a limited scope Short fact gathering investigation. These short investigations are published periodically in Short Investigation Bulletins, which include about 10 individual reports each issue. Refer to the investigation levels in Classifying.”


….then under Classifying and the heading ‘Three Ways to action’ it goes on to say..


“2. A report of an occurrence that may not warrant a full investigation but which would benefit from additional fact gathering for future safety analysis to identify safety issues or safety trends.”


…further down the page under ‘Pros and cons of the second approach’…

“The advantage of the second approach is that a richer data set for a greater number of occurrences is generated with minimal resource overhead which, in turn, is likely to result in improved future research and statistical analysis outcomes. These short, fact gathering investigations also provide an opportunity to upgrade to a full investigation when the initial fact gathering suggests that the issues are more complex and warrant more detailed examination and analysis.” {Note on above in bold : Wonder how many times that has actually happened??}

It is worth comparing the difference in methodology for the classification of investigations with the TSB Canada: TSB Canada- Occurrence Classification Policy

Similar methodology perhaps ..but subtle differences in the wording plus the TSB don’t label investigations as ‘short’, ‘long’ or ‘otherwise’ and on the whole their policy is much more straightforward and transparent.

Okay so does the bureau system achieve the stated objectives or is it, as OA said above, a matter of bumping up the numbers to meet KPIs?

Well without a detailed knowledge of the ATSB database and how the individual short investigations are tagged it is very hard to assess. But going on the wide and varied quality of the short investigations I am somewhat suspicious!!

My bigger concern though is that this system may mask what could be future or developing significant safety issues. By pigeon-holing a serious incident to a less resourced short investigation, therefore (by definition) a shorter summarised final report, are the ATSB running the risk of minimising what could be in other jurisdictions (internationally) a trending significant safety issue???

Hmm..perhaps someone can pick out some examples of the potential for the ATSB investigation classification policy masking significant safety issues from the SIB list??

ATSB ASIB Archive (hint a good place to start is item 9)