Aviation accident investigations

23 May 2013

View the report as a single document - (PDF 1257KB)

View the report as separate downloadable parts:


Membership of committee	(PDF 47KB)

Acronyms and Abbreviations	(PDF 19KB)

List of Recommendations	(PDF 43KB)

Executive Summary	(PDF 28KB)

Chapter 1 - Introduction	(PDF 26KB)
Inquiry terms of reference Conduct of the inquiry Order for the production of documents Acknowledgements Scope and structure of this report

Chapter 2 - Background	(PDF 80KB)
Aviation safety Role of the ATSB Role of CASA The Miller Review and the MoU between the ATSB and CASA Airservices Australia Bureau of Meteorology

Chapter 3 - The ATSB investigation and methodology	(PDF 204KB)
Background Accident investigation analysis model Compliance with ICAO guidelines/structure How the ATSB report falls short The CASA special audit The Chambers Report Retrieval of the flight data and cockpit voice recorders Time taken to produce the ATSB report

Chapter 4 - The ATSB's accident investigation processes	(PDF 280KB)
Overview of the investigation process The ATSB risk matrix Downgrading of the critical safety issue Information withheld from the ATSB How the issue was downgraded Did CASA and the ATSB collude? The way forward Effect of change from BASI to ATSB Expertise of Commissioners Industry experience and risk-based aviation support

Chapter 5 - System failures	(PDF 116KB)
Introduction Scope of the investigation Organisational/operator deficiencies Operational control Fatigue management Conclusions of the Special Audit Other operator issues

Chapter 6 - Regulatory issues	(PDF 115KB)
Surveillance by CASA of Pel-Air The Chambers Report Comparison with overseas reports Conclusion Other issues

Chapter 7 - Communication between CASA and the ATSB	(PDF 36KB)
Background Withholding of key information Breaching the Memorandum of Understanding Breach of the Transport Safety Investigation Act?

Chapter 8 - Human factors	(PDF 105KB)
Importance of human factors Lack of human factors information in the ATSB report Factors influencing decision making Changing weather reports Fatigue Retrieval of the CVR/FDR

Chapter 9 - Key issues around recommendations and ensuring action	(PDF 176KB)
Fulfilling legislative requirements Minister's requirements Why are there no formal recommendations included in the ATSB report? Ability to track action taken in relation to safety issues Safety issues only relevant to specific operators Significant delays implementing ATSB recommendations Areas where recommendations are necessary to ensure actions are taken Passing on relevant weather Critical weather information not passed on Known difficulties in forecasting weather on Norfolk Island Conclusion

Chapter 10 - Changes to mandatory and confidential reporting	(PDF 62KB)
Mandatory reporting Confidential reporting Issues raised with the committee Response from CASA Response from the ATSB

Additional Comments by Senator Nick Xenophon	(PDF 34KB)

APPENDIX 1 - Submissions Received	(PDF 19KB)

APPENDIX 2 - Public Hearings and Witnesses	(PDF 21KB)

For further information, contact:

Committee Secretary
Senate Standing Committees on Rural and Regional Affairs and Transport
PO Box 6100
Parliament House
Canberra ACT 2600
Australia

Phone: +61 2 6277 3511

Fax: +61 2 6277 5811

Email: rrat.sen@aph.gov.au

Phone:	+61 2 6277 3511
Fax:	+61 2 6277 5811
Email:	rrat.sen@aph.gov.au