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Safety data recording, analysis and research

This section describes the ATSB’s performance relating to the ATSB’s role in safety data recording, analysis and research, as published on page 7 of the ATSB Corporate Plan 2020–21.

Data analysis capability

The ATSB continued a data analysis capability expansion program in 2020–21 by:

  • completing a data repository to house copies of all databases used by the ATSB
  • participating in feasibility planning with the Bureau of Infrastructure and Transport Research Economics for a shared multi-agency aviation data warehouse
  • expanding the number of staff trained in the new ATSB Investigation Management System (AIMS).

In 2020–21, the ATSB continued to analyse occurrence data held in its aviation safety occurrence database as part of Australia’s international obligation to determine if preventative safety measures are required.

The ATSB continued to support active aviation occurrence investigations. During 2020–21, the ATSB completed significant data analysis for most aviation occurrence investigations. This work helped to determine the investigation scope, inform investigation conclusions and safety issue risk assessments, and document past occurrences of similar incidents.

Data and recorder recovery

The ATSB’s data and recorder recovery staff maintain support and readiness for the recovery and download of recorded data from a variety of damaged and undamaged sources across the aviation, rail and marine transport modes.

Over this reporting period, the ATSB continued to support external agencies by providing assistance to Recreational Aviation Australia and the Civil Aviation Authority of the Philippines – Aircraft Accident Investigation and Inquiry Board to recover and analyse data from damaged recording devices. The ATSB also made plans to assist the Ministry of Transport, Thailand – Office of the Aircraft Accident and Incident Investigation Commission to download a flight data and cockpit voice recorder in the near future when shipment of the recorders is arranged.

Material failure analysis

The ATSB possesses expertise and specialised facilities to enable the detailed examination of physical evidence, allowing for significant insights into the causes of factors of transport safety occurrences. During 2020–21, transport safety investigators with engineering specialist backgrounds have provided technical input and analysis across a variety of investigations. A selection of tasks included:

  • Examination of components from the ongoing investigation into the Robinson R44 in-flight break-up in Broome, Western Australia (AO-2020-033).
  • Analysis of engine components from the ongoing investigation into the engine failure and forced landing of the Morane-Saulnier MS-893A at Lyons, Queensland (AO-2020-060).
  • A review of the rail wheel disintegration that contributed to the derailment of freight train 2PM9 between Lake Julia and Koolyanobbing, Western Australia (RO-2020-018).
  • Assistance to the Papua New Guinea Accident Investigation Commission in the examination of a fractured landing gear (AE-2020-039).
  • Assistance to CASA in the examination of several aircraft structural components with material failures or suspected defects (AE-2021-029).

Reporting

The ATSB’s target for assessing, classifying and publishing summaries of accidents and incidents is:

  • one day for occurrences being investigated (all modes)
  • 10 days for summaries of other incidents (aviation).

Of 73 occurrences investigated, 42 (58%) were processed with summaries published on the ATSB website within one working day of the start of the investigation.

In 2020–21, 91% of aviation occurrence notifications were processed and ready for publication within 10 working days.

In 2020–21, the ATSB completed 39 occurrence briefs (38 aviation occurrences and one marine occurrence). Eighteen per cent of occurrence briefs were completed within one month.

Confidential reporting

In 2020–21, the ATSB’s Confidential Reporting Scheme (REPCON) received 198 notifications (of which 75 were classified as REPCONs). Of these 198 notifications, 98 concerned aviation (34 REPCONs), 98 concerned rail (39 REPCONs) and two concerned marine (two REPCONs).

Of the 47 REPCON reports completed in 2020–21, 18 (38%) resulted in safety action by stakeholders.

Confidential reports are assessed for clarity, completeness and significance for transport safety. Twenty-eight per cent of de-identified summaries of confidential reports were provided to any relevant third party within 10 working days.

The following summaries provide examples of safety concerns that were raised, along with the safety action taken after the concerns were reported through REPCON. Some information has been redacted to preserve confidentiality.

Aviation REPCON Example

The reporter raised a safety concern relating to an operator’s policy on restraining service dogs on passenger flights. The reporter advised that they had been instructed by the operator’s cabin crew to untie their service dog from the seat or be in breach of complying with a cabin crew direction. As a result, on one occasion, the reporter’s service dog was unrestrained during expected severe turbulence. On that occasion, the turbulence was not as severe as predicted and was uneventful, however, a turbulence event in 2013 resulted in a guide dog being injured and striking another passenger.

The reporter subsequently sought clarification from the operator on their policy for restraining service dogs and was provided with the following response:

The Civil Aviation Act 1988 prohibits a person from tampering with an aircraft if tampering with it may endanger the safety of the aircraft or any person or property. Due to the seat configurations on our aircraft and the different aircraft in our fleet, assistance dogs cannot be consistently and safely tethered to all seats in our aircraft.

Our review has also indicated tethering may damage some seats. We also note that tethering to business class seats is not possible because of the way in which these seats are designed. As part of our review, we have considered alternative means of tethering guide, hearing and assistance dogs (for example, through the seatbelt or under the seat of the guest), however, we determined that these alternatives would also breach CASA requirements preventing tampering with the aircraft. Further, in the event of an evacuation, tethering of the assistance dogs may pose a threat to the safety of others by becoming an obstacle in the row or aisle. For future flights, we ask that you ensure you hold the dog’s lead or place the lead under your person.

The reporter contacted the ATSB to seek clarification on:

  • How the operator determined that tethering the dog to a seat could potentially damage the seat, when all other operators have determined that tethering the dog to the seat does not interfere with aircraft equipment.
  • The relevance of aircraft type, when all aircraft seats, regardless of type of aircraft, must be rated to the same standard.
  • How the service dog is deemed a potential obstacle in an evacuation when the service dog is tethered to a window seat (which is all other carriers’ policy) with their owner beside it. An unrestrained dog in the cabin would likely pose a greater risk of being an obstruction during an evacuation and a violation of CAR 256A.
  • How holding a service dog’s lead or sitting on the lead would comply with the regulations in the event of large acceleration forces that may be encountered.

The reporter was concerned about the risk of injury to a service dog and/or passengers on an aircraft unless the operator amends their policy to align with other airline operators.

As a result of the REPCON, the operator advised they would commence a review of the different seat types in their aircraft fleet to assess whether any of them could be safely used for tethering purposes and without causing damage to the seat. The operator stated that this process would require expert analysis from a range of stakeholders, including an internal engineering team and the seat manufacturers. The operator advised that a decision about its tethering policy would be made on completion of the review, taking into account the review findings and all operational and safety considerations.

The ATSB sought clarification as to whether CASA was satisfied that the operator’s policy for unrestrained dogs was a safety concern. CASA’s response to the REPCON was:

  • CASA has advised AOC holders and updated its website to advise that a suitable way of restraining an assistance dog carried in the aircraft cabin with its handler or trainer would not be achieved by holding the leash or sitting on the leash during times when passengers are required to wear seatbelts. At other times, holding the leash would be satisfactory. Advice will be provided about tethering the dog at other times in the same way as passengers are normally advised to secure their seatbelts at all times when seated.
  • Tethering a dog to a seat rail (or seatbelt) would not breach any airworthiness requirements and would not be ‘tampering’ with an aircraft provided the seat or seatbelt is not physically affected.

CASA updated the information on its website to clarify the requirement to restrain assistance dogs when carried in the aircraft cabin to ensure compliance with CAO 20.16.2. It included advice about tethering and a caution about not interfering with a seat or seatbelt. This information will be included in the new advisory circular on this subject that will come into effect in December 2021.

Marine REPCON Example

A previous REPCON was reopened following the reporter’s concerns that previously agreed safety actions had not been actioned.

The concern related to the safety of cruise ship operations at [Location withheld] operating without tugs in operation or on standby. The reporter was concerned that the risk assessment process to preclude the use of tugboats was insufficient and did not consider any human factor error, which is documented to be a cause or contributing factor in 70% of marine incidents.

The operator initially advised that the procedures for cruise ships entering and departing would be reviewed and risk assessed, and the regulator agreed to review those procedures. However, the reporter advised that this process had not yet occurred despite ample time to do so.

Given the lack of resolution to this safety concern, in 2020 the ATSB contacted the Port Authority outlining residual risk concerns with respect to inclusion of human factors, cyber threats and recent cruise vessel berthing incidents. The Port Authority invited the ATSB to review the draft hazard identification study and navigation risk assessment.

Following a review of the risk assessment, the ATSB advised the Port Authority and the state regulator that:

  • The hazard identification exercise and most of the report’s recommendations appear to be directed at identifying the hazards and mitigating the risks associated with tug-exempt cruise ship scenarios.
  • It is the ATSB’s view that in excluding the option of a mandatory tug escort for cruise ships in the hazard identification and risk assessment exercises, a valuable opportunity was lost to consider and analyse all potential risk control measures.
  • The ATSB notes the report’s assessment that the likelihood of the worst credible scenario – a cruise ship grounding on infrastructure or colliding with a landmark – is extremely low. The assessment is also clear that the consequence of either of these events has the potential to result in a catastrophic loss of life and/or infrastructure.
  • The ATSB acknowledges that implementation of some or all of the recommendations in the Port Authority’s most recent independent commissioned report would likely reduce the risk of an incident involving a tug-exempt cruise ship.
  • The ATSB considered the following points:
  • The number of recommendations aimed at reducing the consequences of an incident involving a tug-exempt cruise ship, including potential modifications to cruise ship departure manoeuvres.
  • The magnitude of any consequences associated with a landmark incident, noting that the landmarks could potentially affect 6,000 people in peak hour traffic, and the force of a cruise ship grounding would most likely lead to an infrastructure collapse.
  • Lack of any evidence to suggest that there is a negative safety impact of tug-escorted cruise ships.
  • Based on this consideration, it is the ATSB’s view that the most demonstrable, effective measure to mitigate the identified risks, is the use of at least one tug for cruise ships navigating the particular location. As such, the ATSB encourages the Port Authority and the regulator to review the current criteria for granting tug exemptions to cruise ships.

The ATSB received advice in early 2021 from the newly appointed Harbour Master, and subsequently confirmed by the reporter, that there are no more tug exemptions being issued to large passenger vessels berthing at the particular location.

Rail REPCON Example

The reporter raised a safety concern about the removal of safety check rails on bridges throughout the operator’s network. The reporter advised that safety check rails were specifically fitted to ensure rolling stock remained on a bridge if derailed. While the check rails have limitations, for lower speed and more minor derailments, the check rails are intended to keep the wheels on the sleepers and prevent the rolling stock from departing the track. The reporter stated that the removal of the rails at a particular bridge location, was a major safety concern.

The reporter stated that this section of track frequently carries high speed passenger services and should a rail vehicle derail on or before crossing the bridge, there would be nothing stopping the rail traffic from plunging into the river below, which obviously has potentially catastrophic consequences.

The operator advised that check rails create maintenance difficulties with loosening fastenings affecting structural integrity and creating a hazard to rail traffic, while restricting ballast tamping at bridge ends and across ballast top bridges.

An expert risk assessment was conducted which determined that safety risks were lowered for bridges without check rails, compared to bridges with check rails. The operator has subsequently worked on the progressive removal of bridge check rails and clarified that new or replacement bridges do not need check rails fitted. A copy of the Risk Assessment and the resultant letter notifying the then Rail Safety Regulator were provided to the ATSB and ONRSR as part of this REPCON.

Particular clauses in the document outline the structural standard that check rails are not fitted to bridges on the operator’s rail network. The operator is working within the requirements of our Safety Management System (SMS) as accredited by ONRSR, and regards our existing standards on bridge check rails as lowering risks So Far As Is Reasonably Practicable (SFAIRP).

ONRSR reviewed the reporter’s concerns and the operator’s response, including additional information accompanying the REPCON report. ONRSR will make further enquiries with the rail transport operator and seek additional information and assurances that risks are being managed SFAIRP.

Statistical reports

In 2020–21, the ATSB published one statistical report:

This report is available on the ATSB website at www.atsb.gov.au.