Aviation accident investigations

Aviation accident investigations

23 May 2013

© Commonwealth of Australia 2013
ISBN 978-1-74229-832-0

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

View the report as separate downloadable parts:

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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
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)

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)

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
Other issues

Chapter 7 - Communication between CASA and the ATSB (PDF 36KB)

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
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

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

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