TERMINOLOGY USED IN THIS REPORT

TERMINOLOGY USED IN THIS REPORT

Safety factors

an event or condition that increases safety risk. In other words, it is something that, if it occurred in the future, would increase the likelihood of an occurrence, and/or the severity of the adverse consequences associated with an occurrence.

The ATSB investigation analysis model is based on the widely used ‘chain-of-events’ theory of accident causation made popular by James Reason’s model of organisational accidents¹ and consists of five levels of safety factors as outlined in Table 1. For more information, see the ATSB publication Analysis, Causality and Proof in Safety Investigations².

Table 1: Safety factors in the ATSB investigation analysis model

Term	Description
Occurrence events (including technical events)	Occurrence events are the key events which describe an occurrence, or the events which ultimately need to be explained by an occurrence investigation. In other words, occurrence events are the safety factors that describe 'what happened'. Technical events refer to the performance of equipment and components involved in the conduct of a transport activity, such as vehicles and their associated parts and systems, as well as supporting facilities (for example, navigational aids, lighting and communication facilities).
Individual actions	Individual actions are observable behaviours performed by operational personnel. The term ‘operational personnel’ refers to any person that can have a relatively direct impact on the safety of a transport activity; for example, flight crew, locomotive drivers, ships’ masters, cabin crew, controllers, dispatch and loading personnel, and maintenance personnel.
Local conditions	Local conditions are those conditions which exist in the immediate context or environment in which individual actions or technical events occur, and which can have an influence on the individual actions or technical events. Local conditions include characteristics of the individuals and the physical environment.
Risk controls	Risk controls are the measures put in place by an organisation to facilitate and assure safe performance of the operational components of the system (that is, operational personnel and equipment). They can be viewed as the outputs of the organisation’s safety management system. Risk controls are sometimes termed ‘defences’, ‘safeguards’ or ‘barriers’, although some definitions of these terms can vary in scope.
Organisational influences	Organisational influences are those conditions that establish, maintain or otherwise influence the effectiveness of an organisation’s risk controls. There are two main types of organisational influences: organisational conditions and external influences.

(a) the occurrence would probably³ not have occurred or

(b) the adverse consequences associated with the occurrence would probably not have occurred or have been as serious or

(c) another contributing safety factor would probably not have occurred or existed.

Safety issues

A safety issue is a safety factor that:

(a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and

(b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operational environment at a specific point in time.

Therefore, the primary way for ATSB investigations to improve transport safety in the future is through the identification and mitigation of safety issues. As such, this report, while documenting all safety factors identified through investigations, will focus on safety issues and safety actions resulting from ATSB investigations.

Risk level

When safety issues are identified to pose an unacceptable level of risk, the ATSB will seek safety action from the relevant organisation. Safety issues are broadly classified in terms of their level of risk as follows:

Critical safety issue: associated with an intolerable level of risk and generally leading to the immediate issue of a safety recommendation unless corrective safety action has already been taken.

Significant safety issue: associated with a risk level regarded as acceptable only if it is kept as low as reasonably practicable. The ATSB may issue a safety recommendation or a safety advisory notice if it assesses that further safety action may be practicable.

Minor safety issue: associated with a broadly acceptable level of risk, although the ATSB may sometimes issue a safety advisory notice.

Safety issue risk reflects the risk level as it existed at the time of the occurrence. It is widely recognised that all modes of transport will always operate with some level of risk, but that this risk should be as low as reasonably practical. Generally, the ATSB considers that the risk associated with any minor safety issue it identifies is at an acceptable level. By contrast, the risks associated with significant or critical safety issues are considered unacceptable. If the organisation or agency responsible for an identified safety issue does not take steps or propose to take steps that reduces the risk to an acceptable level (referred to as safety action), the ATSB will consider issuing a formal safety recommendation.

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