ATSB investigations primarily improve transport safety by identifying and addressing safety issues. Safety issues are events or conditions that increase safety risk and:
- can reasonably be regarded as having the potential to adversely affect the safety of future operations
- are characteristics of an organisation or a system, rather than of a specific individual, or operational environment at a specific point in time.
Safety issues will usually refer to an organisation’s risk controls, or to a variety of internal and external organisational influences that impact the effectiveness of its risk controls. They are factors for which an organisation has some level of control and responsibility and, if not addressed, will increase the risk of future accidents.
The ATSB prefers to encourage stakeholders to take proactive safety action to address safety issues identified in its reports. Nevertheless, the ATSB may use its powers under the TSI Act to make a formal safety recommendation either during or at the end of an investigation – depending on the level of risk associated with a safety issue and the extent of corrective action already taken.
When safety recommendations are issued, they clearly describe the safety issue of concern, but they do not provide instructions or opinions on a preferred corrective action. Like equivalent overseas organisations, the ATSB has no power to enforce the implementation of its recommendations. It is a matter for the organisation to which an ATSB recommendation is directed to assess the costs and benefits of any means of addressing a safety issue, and act appropriately.
When the ATSB issues a safety recommendation to a person, organisation or agency, they must provide a written response within 90 days. That response must indicate whether they accept the recommendation, any reasons for not accepting part or all of the recommendation, and details of any proposed safety action to give effect to the recommendation.
The ATSB can also issue a safety advisory notice (SAN) suggesting that an organisation, or an industry sector, consider a safety issue and take appropriate action. There is no requirement for a formal response to a SAN.
Safety issues are broadly classified in terms of their level of risk:
- Critical safety issue – associated with an intolerable level of risk and generally leading to the immediate issue of a safety recommendation unless corrective safety action has already been taken.
- Other safety issue – associated with a risk level regarded as unacceptable unless it is kept as low as reasonably practicable. Where there is a reasonable expectation that safety action could be taken in response to reduce risk, the ATSB will issue a safety recommendation to the appropriate agency when proactive safety action is not forthcoming.
All ATSB safety issues and associated safety actions, along with the most recent status, are published on the ATSB website for all investigation reports released since July 2010.