Cause & effect and the four year cycle
While the miniscule & his team of dept crats are otherwise distracted with balancing the books for 2014-15, the Ferryman’s last perhaps provides a welcome diversion from the future ‘doom & gloom’ of TA’s budgetary crisis..
Kharon: "..But I get the feeling that the ATSB site almost deliberately sets out to confound, the NTSB and other agencies all seem to have open, easy to navigate sites (by comparison). Some even offer to facilitate 'your research' if it's abstruse, for a modest fee (of course)..."
Beaker & Co should have nothing to hide so why the seemingly impenetrable website?? The ATsB’s primary function is to promote open & free dissemination of vital safety findings, lessons, research and recommendations to further enhance safety risk mitigation for the greater worldwide aviation industry. Beaker should be promoting the good work his investigators, researchers & data entry folk are doing on the coalface. So why is the ATsB (in its current form) so obtuse (almost retrograde) in how they go about their primary function??
The four year cycle
As long as we can all remember the, once beloved, bureau (BASI/ATSB) had always been the cash strapped poor cousins to the FF behemoth. Yet with limited resources they still punched above their weight and in accordance with Annex 13 were lorded as setting a benchmark for a small but effective State AAI.
It wasn’t till 2000 with the Whyalla accident investigation that the wheels started to fall off and for the first time the bureau started to cop independent, external & international flak.
Then we had the 2004 ICAO audit of the ATsB which came up with the following finding and recommendation in regards to compliance with Annex 13:
FINDING:
The ATSB’s policy is to place the primary focus on fare-paying passengers and to investigate all fatal accidents (unless they involve sport aviation). However, accidents that are considered to have little potential benefit for prevention may not be investigated in detail. In such cases, the ATSB would not necessarily attend the scene,conduct an in-depth investigation or produce an extensive report.
RECOMMENDATION:
The ATSB should investigate all accidents as defined by Annex 13. The depth of such investigations should be at least to a level where it is evident that no further enhancement of aviation safety can be achieved.
To which the ATSB responded with this:
CORRECTIVE ACTION PROPOSED BY THE ATSB:
This recommendation is related to the earlier recommendation at Appendix 2-2 and the ATSB response at 2-2 is also relevant. The ICAO audit recommendation that all accidents should be investigated at least to a level where it is evident that no further enhancement of aviation safety can be achieved has significant budgetary implications that are outside of the control of the ATSB. While many accidents are essentially repetitive and involve little new safety learning and diminishing returns in their investigation, it is rarely possible to be so absolute as to assess that no further enhancement of aviation safety can be achieved by further investigation.
The ATSB will, before the end of August 2004, advise the Deputy Prime Minister and Minister for Transport and Regional Services, the Departmental Secretary and the Department of Finance and Administration of the audit recommendation and its budgetary implications.
Which led to a rather prolonged action response:
ACTION TAKEN BY THE ATSB:
The ATSB formally briefed the Deputy Prime Minister and Minister for Transport and Regional Services on the final ICAO Audit and its recommendations by Minute dated 22 October 2004. This Minute was also the formal mechanism for briefing the Department of Transport and Regional Services (DOTARS) Secretary and Deputy Secretaries. The ATSB briefed the Department of Finance and Administration (DOFA) at Division Head level on the ICAO Audit with a focus on recommendations CE-3/02 and CE-5/03 on 23 November 2004 via the Department of Transport and Regional Services’s Chief Financial Officer. On 21 December 2004 the Department of Finance and Administration responded that any additional funding was a matter in the first instance for the Minister's consideration against other priorities in his portfolio. DOFA stated also that only proposals with specific authority from the Cabinet or the Prime Minister were eligible for budget consideration.
In 2007-08 the ATSB was funded to undertake approximately 80 new aviation safety investigations of which about 30 are of the more comprehensive variety. Choice of the 80 from approximately 8000 accidents and incidents reported was based on published selection criteria. In addition, for the financial years 2007-08 to 2009-10 the ATSB was provided with additional budget funding to assist Indonesia with its transport safety improvement program.
But despite these initiatives, on the next four year cycle the bureau copped this finding & recommendation, again from ICAO {It is worth noting that 2008 was when Beaker first started his tenure and there was an underspend in the fiscal year 2008-09}:
AUDIT FINDING AIG/01
Funding for aviation accident investigations is provided by the Federal Government of Australia through the Department of Infrastructure, Transport, Regional Development and Local Government.
To make the most of the funding allocated to it, the Australian Transport Safety Bureau (ATSB) has established guidelines to determine whether to investigate an occurrence with the level of response to a notification determined by resource availability and such factors as:
1. existence of fatalities;
2. anticipated safety value of an investigation;
3. extent of public, media or political interest;
4. timeliness of notification;
5. training benefit for ATSB investigators;
6. likely possibility of safety action arising from the investigation or the existence of supporting
evidence or requirements to conduct a special investigation based on trends;
7. safety analysis or an identified targeted programme; and
8. scope or impact of any system failures.
Under the ATSB guidelines, occurrences that may fit the ICAO Annex 13’s definition of an aircraft accident or incident may not be investigated. Although the ATSB submits a notification of these occurrences to ICAO in accordance with ICAO Annex 13 provisions, the ATSB does not submit a preliminary report and/or an accident data report identifying contributing safety factors or probable cause.
And the response & action plan:
STATE’S COMMENTS AND OBSERVATIONS*
Australia has considered this finding and the related recommendations from the audit team.
Australia meets its Article 26 obligations. However, Australia has also lodged a difference with ICAO in relation to standard 5.1 and recommended practice 5.1.1 of Annex 13 as Australia considers it impractical to investigate all accidents and serious incidents within resources available. In addition to targeting those accidents and incidents that are likely to yield the greatest safety value in accordance with the guidelines quoted above, Australia normally gives priority to investigations of accidents and serious incidents involving regular public transport aircraft (especially with fare-paying passengers) and accidents involving fatalities other than those involving ultralights and sport aviation.
Australia notes that the investigation of accidents and serious incidents has been included for
discussion at the ICAO Accident Investigation and Prevention (AIG) Divisional meeting in October 2008. ATSB will participate in this discussion as it relates to upgrading recommendation 5.1.1 to a standard and allocating resources to those investigations that will yield the greatest safety value.
Australia may review its investigation policy following the AIG meeting.
Which led to the notified differences (highlighted by SIUYA) recorded in the ASA AIP SUP H12/11 in 2011 {Note: More on the notified differences later because there is some rather disturbing additions in the latest H18/14 SUP}.
Then we fast forward a further 4 years to the PelAir inquiry where we had another independent external body (i.e. the Senate Committee) which was heavily critical of the ATsB using lack of resources as an excuse to not thoroughly investigate (as per Annex 13) the Norfolk VH-NGA ditching. The Committee also made this recommendation:
Recommendation 9
4.103 The committee recommends that the government develop a process by which the ATSB can request access to supplementary funding via the minister.
More to follow on bean counter Beaker’s fiscal discipline, his new notified differences to Annex 13 & the history of REPCON (WOFTAM)…
