Atsb transport safety report
Classifying investigations
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- The investigation levels
- OVERVIEW – ALL MODES
Classifying investigationsTransport safety matters reported to the ATSB can be dealt with in three different ways to contribute to the ATSB’s functions.
In the third approach, the occurrence is not investigated immediately, but may be the subject of a future investigation. 
Collision between XPT passenger train WT27 and a track-mounted excavator near Newbridge, New South Wales (RO-2010-004) The investigation levelsInvestigations are classified by the level of resources and/or the complexity and time required to complete the investigation as per Table 2. Table 2: ATSB investigation classifications
The Level 5 investigations are a new initiative by the ATSB in 2010. The resultant summary report is a compilation of the information the ATSB has gathered, sourced from individuals or organisations involved in the occurrences, on the circumstances surrounding the occurrence and what safety action may have been taken or identified as a result of the occurrence. For aviation, these investigations are published in a bulletin each quarter, with the first edition published in April 2010. OVERVIEW – ALL MODESInvestigationsDuring the 2009-2010 financial year (1 July 2009 to 30 June 2010), the ATSB completed 90 occurrence and safety issue investigations across the aviation, marine and rail modes. Of these investigations, there were 58 comprehensive investigations (levels 1 to 4) involving the identification of safety factors through the ATSB investigation analysis model (Table 3). The ATSB investigation analysis model is based on the ‘chain-of-events’ theory of accident causation made popular by James Reason and is made up of the five levels of safety factors (see Table 1 in TERMINOLOGY USED IN THIS REPORT). This report will provide analyses of the safety factors, safety issues and safety actions arising from these 58 investigations. Details about these investigations are presented in Appendix A. There were two rail occurrences investigations (external occurrences) which the ATSB participated in under Queensland legislation. The ATSB investigations of these occurrences identified safety factors which are documented in this report. Safety actions from these investigations were in the responsibility of the State of Queensland and so have been excluded from this analysis. Table 3: Number of level 1 to 4 investigations completed in 2009-2010 financial year
Grounding of Breakthrough at the Cocos (Keeling) Islands (MO-2008-003) The ATSB also participated in 11 external aviation investigations and one marine occurrence investigation in addition to those documented in Table 3. However, they are not included in this report as these investigations involved only the initial stages of the investigation and not the analysis of safety factors. Details about these external investigations can be found in the ATSB Annual Report 2009-2010. In addition, there were 19 level 5 aviation factual investigations completed in 2009-2010. As these investigations do not involve the identification of safety factors through the ATSB’s formal analysis methodology, the results from these factual-only investigations are not included in this report. It can be seen in Table 4 that all 58 investigations completed in 2009-2010 were level 3 and 4 (see BACKGROUND for information on the ATSB investigation classifications). Table 4: Number of investigations completed by investigation level in 2009-2010 financial year
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