Atsb transport safety report



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Safety issues identified


Table 5 shows that there were 124 safety issues identified by the ATSB in investigations in the 2009-2010 financial year. There were no critical risk safety issues identified. (See Risk level on page 11 for risk level definitions.)

Table 5: Number of safety issues identified by risk level in 2009-2010 financial year





Transport Mode

Minor risk

Significant risk

Critical risk

Total

Aviation

34

12

0

46

Marine

13

27

0

40

Rail6

25

13

0

38

Total

72

52

0

124

In aviation and rail investigations, more of the safety issues identified were of minor rather than significant risk, while in marine investigations, more safety issues were of significant rather than minor risk.

The number of investigations completed for each mode differs and thus, for the purpose of comparing across modes, the number of safety issues identified per investigation is shown in Figure 1. Both marine and rail investigations revealed more safety issues per investigation than did aviation. This may reflect the nature of rail and marine investigations in that most investigations involve very large and commercial transport vehicles, while aviation investigations also include small aircraft and non-commercial operations. Moreover, marine investigations identified more safety issues with significant risk per investigation than did the other transport modes.

Figure 1: Safety issues identified per investigation completed in 2009-02010 financial year

In rail and aviation, level 3 investigations, which are more complex and greater in scope than level 4 investigations, led to more safety issues being identified (both in total and at the significant risk level). However, as seen in Figure 2, marine investigations did not conform to this expectation.

Figure 2: Number of safety issues identified by risk level and investigation level in 2009-2010 financial year

The details concerning the safety issues specific to each mode of transport are discussed in the following chapters.


Safety actions


Table 6 below depicts the number of safety actions that have been undertaken that address safety issues identified by ATSB investigations in each of the transport modes. (See Safety action on page 11 for definitions of safety action types.)

Table 6: Safety actions identified in ATSB investigations (2009-2010 financial year)








Aviation

Marine

Rail

Total

Proactive industry safety action

60

34

14

108

ATSB Safety Recommendation

1

4

8

13

ATSB Safety Advisory Notice

2

10

5

17

ATSB Safety Awareness Activity

2

0

0

2

ATSB Additional Safety Investigation  

1

0

0

1

Total

66

48

27

141

Aviation investigations recorded more safety actions than the other modes as would be expected from the higher number of investigations and safety issues identified. Figure 3 shows the different types of safety actions that were identified per investigation for each transport mode. Overall, marine investigations prompted the most safety actions per investigation, followed by rail investigations.

Fatality on board Spirit of Esperance at Townsville, Queensland (MO-2008-011)

Proactive industry safety actions are encouraged before the release of any formal ATSB safety action, and so generally, the ATSB issues safety recommendations and safety advisory notices (SANs) as a last resort. This is reflected in all transport modes having more proactive industry safety actions than formal ATSB safety actions per investigation.

Rail and marine investigations produced more safety recommendations and SANs, both in total and per investigation, than aviation investigations. Rail investigations delivered more safety recommendations per investigation than marine investigations, but marine investigations resulted in more SANs than rail investigations.

Additional ATSB safety investigations and safety awareness activity were carried out as a safety action to address an identified safety issue only in the aviation mode.

Figure 3: Safety actions per investigation completed in 2009-2010 financial year



More details about safety actions in each of the transport modes are presented in the following chapters.





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