Atsb transport safety report
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- Safety Recommendation
- Safety Advisory Notice
- Safety Awareness Activity
- BACKGROUND
- Priorities for investigating
Safety actionSafety actions are the steps taken or proposed to be taken by a person, organisation or agency in response to a safety issue. They can be classified into the following types:
Proactive industry safety action refers to local or systemic action taken by an organisation or individual in response to the findings of an ATSB safety investigation (or other investigation into the matter being investigated by the ATSB), prior to the release of any ATSB safety action.
In contrast, ATSB safety action refers to formal activities conducted by the ATSB to initiate additional safety action by relevant organisations. ATSB safety action, such as issuing safety recommendations and safety advisory notices, is normally a last resort and is generally taken when other attempts to facilitate sufficient safety action have not been successful, and the risk level is still assessed as either critical or significant (and not as low as reasonably practical). 
Main rotor blade skin debonding (AO-2009-002) Types of ATSB safety action include:
ATSB Additional InvestigationSometimes occurrence investigations suggest the possibility of a larger safety issue that is beyond the scope of the investigation to investigate. These can result in ATSB safety action of initiating a safety issue investigation. BACKGROUNDThe Australian Transport Safety Bureau (ATSB) is an independent Commonwealth Government statutory Agency that conducts independent investigation of: aviation accidents and serious incidents involving Australian civilian-registered aircraft anywhere in the world and foreign aircraft in Australia marine accidents and serious incidents involving Australian registered ships4 anywhere in the world, foreign flag ships within Australian waters, or where evidence relating to an accident involving ships is found in Australia rail accidents and serious incidents that occur on the Defined Interstate Rail Network (DIRN). The ATSB has developed a comprehensive investigation analysis framework. As part of this, safety investigations aim to identify safety factors, and in particular safety issues and resultant safety actions. Each year, the ATSB conducts about 100 investigations into transport safety matters in aviation, rail and marine. Most of the resultant investigation reports document safety issues identified during the investigation, along with the assigned risk level for each safety issue. The ATSB also individually documents safety actions completed by industry and regulators in response to the identified safety issue(s). When no or inadequate safety action occurs, the ATSB may also release a safety recommendation, which is required to be responded to by 90 days. This report will document the ATSB-identified safety issues and related safety actions for the 2009-2010 financial year in all three transport modes (aviation, marine and rail). It will explore the risk levels assigned and provide an understanding of where the greatest risks to each transport mode appears to lie, recognising that the results are partial, given the limits of investigation activity. The results will nevertheless be useful for government decision makers, and regulators and the aviation, rail and marine industries to understand if and where greater attention needs to be applied to risk. Priorities for investigatingThe ATSB's primary investigation focus is on enhancing safety with respect to fare paying passengers, and in particular, those transport safety matters that may present a significant threat to public safety and are the subject of widespread public interest. The ATSB therefore needs to direct significant attention to identifying systemic failures in aviation, marine and rail mass public transport systems that have the potential to result in catastrophic accidents and which are often characterised by large numbers of fatalities and serious injuries. 
Total power loss at Talbot Bay, Western Australia (AO-2008-067) The following broad hierarchies for aviation, marine and rail which reflect the priorities described above must be taken into account when deciding whether or not to investigate and in determining the level of investigation response.
The aviation broad hierarchy is as follows:
RPT and charter humanitarian aerial work (for example, RFDS, SAR flights).
non-passenger carrying aerial work (for example, agriculture, cargo) private transport/personal business.
Marine The marine broad hierarchy is as follows:
Rail The rail broad hierarchy is as follows:
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