11

Partnerships & Cooperation in anEnvironment of ResourceConstraints & Security Imperatives

Kym Bills

Executive Director ATSB

Chiefs of Aircraft Accident Investigation

Singapore, 23 August 2007

22

Overview

• There is a tension between independent safetyinvestigation with accident site control and otherlegitimate investigation that entails cooperation

• Also, resource constraints affect most States

• The tension is exacerbated by growth of securityin terms of resources and uncertainty whether anevent is the result of unlawful interference

• Cooperation with other investigations withappropriate boundaries will be critical, alsobilateral and regional partnerships/MOUs

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ATSB

• Operationally independent multi-modal body toinvestigate, analyse & report on aviation,interstate rail & marine safety occurrences

• The ATSB is part of the Australian GovernmentDepartment of Transport and Regional Services(DOTARS) for administration and resourcing

• However, neither the Minister nor DepartmentalSecretary can influence investigations (Section 15of the Transport Safety Investigation Act 2003)

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• The ATSB is separate from:

– state bodies like Police and rail regulators, and

– federal bodies like the Civil Aviation Safety Authority(CASA) & the Australian Rail Track Corporation (ARTC)

• Also within DOTARS is the Office of TransportSecurity (OTS), the Federal transport securityregulator, which has grown from about 50 to about350 staff since 9/11

– cf the ATSB 115 staff

– (Federal Police/ASIO growth also rapid)

ATSB

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ICAO audits

• Following the UK AAIB’s lead, the ATSB soughtan ICAO Annex 13 audit, which was held in 2004and posted the results on the ATSB website

• Several recommendations concerned resources

– determining staff needed to adequately complete allAnnex 13 tasks and being resourced accordingly; and

– investigating all accidents defined by Annex 13 ‘to atleast the level where no further enhancement ofaviation safety can be achieved’.

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ICAO audits

• While the ATSB received additional resourcesjust ahead of the audit, like most colleagues itcontinues to have an annual budget it mustwork within

• ‘Party system’ is not really practicable for us

• Hence ‘investigation’ of all accidents (manysport aviation etc), as investigation is definedin Annex 13 is not possible, especially ifselected incidents with more safety value areto be investigated meaningfully

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Annex 13 definitions

• Annex 13 defines investigation:

– A process conducted for the purpose of accidentprevention which includes the gathering and analysisof information [all available per paragraph 5.4astandard], the drawing of conclusions, including thedetermination of causes and, when appropriate, themaking of safety recommendations

• As you know in Annex 13 ‘causes’ are:

– Actions, omissions, events, conditions, or acombination thereof, which led to the accident orincident

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Resourcing

• Realistically, barring a major accident (cf BEAfunding post Concorde) the ATSB will struggle tomaintain real terms funding

• Luckier than some colleagues

– eg TSB of Canada and NTSB do a wonderful jobgiven their budget reductions this decade

• The challenge for us all is to glean the greatestsafety benefit from limited budgets, whilerespecting the integrity of the ChicagoConvention and Annex 13

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International investigations

• The ATSB is a small player for non-domesticaccidents, compared with the States (countries) ofdesign and manufacture like NTSB, BEA, UK AAIB

• In addition to recorder assistance, ATSB majorinternational investigation assistance included:

– 1997 SilkAir MI185, 737-300, Palembang Sumatra

– 1999 Qantas QF1, 747-400, Bangkok

– 2000 Singapore SQ 006, 747-400, Taipei

– 2003 Laos, IL76, Baucau East Timor

– 2007 Garuda GA200, 737-400, Yogyakarta Java

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International cooperation

• The Chicago Convention and its Annex 13 ispredicated on international cooperation

• The ATSB has been very appreciative in recentyears of colleagues like the NTSB, TSB, BEA,UK AAIB, AAIB-Singapore, Hong Kong CAA andIAC assisting with engine tear-downs andcomponent examination etc

• In what can be a rather lonely and stressful job, itis great to have the support of colleagues

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International cooperation

• In addition, the international investigations wehave contributed to have all included assistancefrom colleagues for which we are very grateful

• Unlike some colleagues, Australia doesn’t have amajor role as country of design or manufacture

• From the outset, we have signed MOUs andLetters of Intent to underpin Annex 13 with anumber of countries who are not members of theInternational Transportation Safety Association(ITSA), to foster good relationships/contacts

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Independent investigation

• For investigation of many more complex events, aseparate no-blame investigation is essential

• The Transport Safety Investigation Act 2003

provides for independence and importantly,primacy of evidence unless an act of unlawfulinterference has been determined

• For the latter, Australia has also established aseparate no-blame security investigator

• For less resourced countries, regional partnershipsmay be a solution

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Regional cooperation

• The Interstate Aviation Commission (IAC or MAK)provides a model of 12 states cooperating inaviation investigation

• As others know better than I, the IAC has donemuch technically excellent work and there is someconsideration of possibly improving governance(eg separating out certifying regulatory functions)

• Other regions are looking at cooperation

• ICAO is supportive of such developments

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Regional cooperation

• In Australia’s immediate region, the PacificAviation Safety Office (PASO) has beenestablished in Vanuatu to coordinate aviationregulation

• A future project may involve establishing anindependent Pacific aviation investigation body tohandle major accidents

• Current resources make investigation difficult &there are legal blocks (eg PNG no legislation)

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Sharing IT and methodology

• May 2004 Budget the ATSB was funded $6.3m over 4financial years to develop a new Safety InvestigationInformation Management System (SIIMS)

• By the end of 2007 this project will be complete foraviation, as well as for marine and rail

• The ATSB worked with Canada’s TSB on aspects ofthe system, as both bodies were using similarconcepts and software (TSB TIIMS)

• SIIMS was an opportunity to change investigatorculture re risk analysis, project management, tighterinvestigation analysis and overall methodology

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ATSB business context - aviation

SIIMS

Notifications &

Data Entry

Investigation Investigation

Team B

Investigation

Team C

Safety outputs

Manual

Occurrence reports

Research &

Analysis

Occurrence

Records

Occurrence reports

Safety Investigation

information

Aviation Industry

Operators

Regulators

Owners

Manufacturers

ATSB Safety Investigation Context

Investigation Resource

Management information

Management

Electronic

Occurrence reports

Public

Safety Information

Safety Information

aviation

occurrences

Evidence

Evidence Information

Communicate

Safety

Record

Occurrences

Investigate&

Analyse

Investigation

Project Management

information

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SIIMS

• Key design principle - simplicity/usability

- worldwide review, but as 7000 aviation occurrenceseach year plus historical data, ECCAIRS ultimatelynot best choice (but SIIMS is ICAO compatible)

- use off-the-shelf software where possible, egMicrosoft Sequel database, Sharepoint

- data collection & coding standardised

- events are coded if common/important

• Happy to share our learnings (eg Mike Walker)

• Trialed methodology and SIIMS with a largeaviation accident investigation concluded 2007

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Using SIIMS methodology – CFIT

11 km NW Lockhart River Aerodrome

7 May 2005, RPT 2 crew/13 pax fatalities

VH-TFU, SA227-DC (Metroliner 23)

Safety Investigation

200501977

1919

South Pap

Accident site

2020

Contributing safety factors

• Defined as a safety factor that, if it hadn’toccurred/existed … the accident would probablynot have occurred … or another contributing safetyfactor would probably not have occurred or existed(>66% likely/probable, >90% very likely)

• Diagram shows

– 19 contributing safety factors (black border)

– 13 of the 21 other safety factors (purple outline)

• Evidence not sufficient for some (eg CRM)

The acci-map diagram is built from bottom up

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Other investigations

• Separate investigations by regulators, OHS bodies,police & security authorities occur consistent with a‘just culture’ (c10% ‘accidents’ via culpable actions)

• ATSB no-blame safety investigations are only onepart of the system and we cooperate to enable otherauthorities (including security agencies) to do theirjobs in parallel where this is necessary

• Coroners and civil courts generally use balance ofprobabilities lower test while criminal cases use thetougher ‘beyond reasonable doubt’ (ours in betweencf intergovernmental climate change panel usage)

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Security imperatives

• Annex 13 paragraph 5.11:– If, in the course of an investigation it becomes known,

or it is suspected, that an act of unlawful interferencewas involved, the investigator-in-charge shallimmediately initiate action to ensure that the aviationsecurity authorities of the State(s) concerned are soinformed

• ATSB’s investigation legislation allows for this, asdoes our voluntary confidential reporting legislation

• If we get information about serious criminality or animminent risk we also need to be able to disclose it

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Security imperatives

• As is well-known, the real ‘fun’ starts after a crashwhen it is unclear whether it is an accident or theresult of terrorism/criminality

• The NTSB’s experience with TWA800 and the FBIwas salutary and apparently led to a relativelysmooth procedure for the New York A300

• The ATSB has not been able to sign MOUs withpolice and security agencies pending legislativeamendment, but is seeking to build relationships inthe interim

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Cockpit doors investigation

• Of course, when the ATSB conducts aninvestigation that involves negative comment on asecurity agency, this doesn’t increase popularity

– but it is our role

• In 2005 we received reports of some unintendedconsequences associated with the fitment ofhardened cockpit doors to passenger aircraft with aseating capacity of 30-59 seats, including someminor crew injuries

– an investigation was initiated

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Cockpit doors investigation

• The investigation (ATSB report 200504018) foundthat a combination of time pressure, and lack ofrisk assessment and input from the regulator ledto a key FAR omission

• Unlike the keypads for larger aircraft, there wasno way for cabin crew to access the cockpit ifboth flight crew were incapacitated

• Also, flight crew could not open a hardened doorfrom their seats, so if one pilot was incapacitated,the other pilot needed to leave the flight controls

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Conclusion

• There is a tension between independent safetyinvestigation with accident site control and otherlegitimate investigation that entails cooperation

• Also, resource constraints affect most States

• The tension is exacerbated by growth of securityin terms of resources and uncertainty whether anevent is the result of unlawful interference

• Cooperation with other investigations withappropriate boundaries will be critical, alsobilateral and regional partnerships/MOUs.