Scope of TSB independent objective peer review of ATSB
Proposed Objectives
To provide the ATSB with an independent objective peer review of its investigation process/ methodology, and of the application of its methodology to at least two selected occurrences (including the Norfolk Island occurrence).
To identify best practices from both organizations that would be shared to improve existing processes and methodologies.
Proposed Scope of Work
1 — Exclusions
The TSB will not re-investigate the Norfolk Island occurrence and will not provide an ‘investigation report’ specific to this occurrence.
This review will be internal to the TSB and ATSB only. The TSB will not communicate with, or interview, any persons external to the ATSB as part of this review.
2 — Review of the Investigation Methodology
The TSB will collect information and conduct a comparative analysis of the ATSB and TSB investigation methodologies, including the approach for the risk assessment of safety issues. The analysis will also include a comparison the two methodologies to the relevant provisions of Annex 13 to the Chicago Convention. This benchmarking analysis will identify the strengths (best practices) and the weaknesses (gaps) of each methodology.
3 — Application of the Investigation Methodology
The TSB will review the Norfolk Island investigation and at least one other ATSB investigation to assess whether the investigation methodology was properly applied. The review team will ask questions such as: Was the process followed? Were the proper tools, systems and resources in place and effectively used? Was the investigation conducted in a thorough manner? Was all significant information adequately considered and analysed? Were organizational and human factors adequately considered? Would we have done things differently? This review will identify any best practices and any issues or gaps in the application of the existing methodology.
4 — Management and Governance of the Investigation
The TSB will review the Norfolk Island investigation and at least one other ATSB investigation to assess the ATSB’s approach to the management and governance of the investigation process. The review team will ask questions such as: How was the investigation managed? How were key decisions made and by whom? Was there adequate documentation and guidance to support decision-making? Were the key decisions based upon solid factual information and robust analysis? Would we have done things differently? Are there any legislative impediments to the conduct of ATSB investigations? This review will identify any best practices and any issues or gaps in the governance and management of the investigations.
5 — Investigation Report Process
The TSB will review the ATSB investigation report process and how it was applied in the case of the Norfolk Island investigation and at least one other ATSB investigation to assess its effectiveness at achieving the desired outcome. The review team will ask questions such as: Was the process followed? Was the report review conducted in a thorough manner and was it effective? Is the analysis contained in the report complete and thorough? Are the findings and recommendations well supported by facts and robust analysis? Were the comments received from directly involved parties adequately considered and was the disposition of these comments full communicated? Would we have done things differently? This review will identify any best practices and any issues or gaps in the investigation report review process.
6 — External Communications
The TSB will review the ATSB approach to external communications (i.e. vis-à-vis the media, public, stakeholders and politicians) throughout the investigation and report production process, upon the release of the final report, and in the weeks following the report publication to assess its effectiveness at achieving the desired outcome. The review team will ask questions such as: What was the methodology and was the process followed? Was information provided in a proactive manner? Were messages crafted with the anticipated stakeholder reaction in mind? After looking at the business process, the TSB will look into the communications issues specific to Norfolk Island and its aftermath. The review team will ask further questions such as: Was the reaction appropriate in response to the television show Four Corners? Why was the ATSB unable to convince the Senate Committee and possibly the public of the validity of its processes? Would we have done things differently? This review will identify any best practices and any issues or gaps in the external communications process.
7 — Deliverables
The TSB will prepare and submit a detailed written report to the ATSB summarizing the results of its review, its findings and its recommendations. The report will contain the following sections:
- Introduction
- Description of the review process and methodology
- Analysis and findings for each section
- Review of the Investigation Methodology
- Application of the Investigation Methodology
- Management and Governance of the Investigation
- Investigation Report Process
- External Communications
- Conclusion and recommendations
The TSB will provide a draft report to the ATSB for review and comments. The ATSB comments will be considered by the TSB and the report will be finalized.
8 — Independence
The TSB will carry out the work described in the preceding sections in an independent and objective manner. The TSB will be fully responsible for the conduct of the review and for the analysis of the information collected. The final report will present the independent views of the TSB.
In the interest of transparency and accountability, the TSB will make its final report public (i.e. post it on its web site). Advanced notification of the release and advanced copies of the report will be provided to the ATSB. Once the report is public the ATSB will be able to reference the report and disseminate it as it sees fit without any restrictions.
The ATSB will provide full cooperation and access to the necessary files, manuals, policies, procedures, and personnel.