NOHSC Effective Incentives Forum Melbourne, 16 October 2001

1. NOHSC Effective Incentives Forum Melbourne, 16 October 2001 “Effective safety incentives in road, air, marine and rail”Kym Bills, Executive Director ATSB

2. Australian Transport Safety Bureau (ATSB) An operationally independent Bureauwithin the Commonwealth Department of Transport and Regional Services- Exec Director statutory powers but accountability to Sec/Minister eg for PS Act & FMA Act purposes

3. Overview of ATSB • 110 staff, nearly 70 involved in investigations including 9 in Brisbane and Perth offices - modal specialists, human factors, technical analysis • others in road safety, information release • Annual budget $13-14m ($20m with overheads) determined via Dept budget • ATSB takes a broad view of ‘effective incentives’ in transport safety.

4. ATSB Objective SAFE TRANSPORT

5. ATSB Mission • To maintain and improve transport safety and public confidence through excellence in: • open and independent ‘no blame’ transport accident, incident and safety deficiency investigation

6. ATSB Mission • safety research and data analysis • safety communication and education, and • safety programs, including the cost effective treatment of road safety black spots.

7. Comparable modal data • Road almost 1,800 fatalities and 23,000 serious injuries per annum ($15b pa) • Marine, Aviation and Rail each about 50 fatalities per annum- serious injuries nearly 500 pa Marine, 200 pa Aviation and 120 pa Rail • Biggest gains in road safety but biggest sensitivities re fare-paying passengers esp. avoiding major accident in aviation

8. Effective road safety incentives • Major reduction in fatality rate since 1970 when 3,798 fatalities (30.4 per 100,000) • Per 10,000 vehicles 8.0 to 1.5 reduction • Good progress in first national strategy from 1992 until plateau from 1997 and worsening in 2000 (improved in 2001) • Needed a renewed commitment • ATSB coordinated a new national road safety strategy and action plan from 2001

9. Road safety trends

10. Effective road safety incentives • NRSS 2001-10 & Action Plan 2001 & 2- key target to reduce fatality rate from 9.3 per 100,000 to 5.6 by 2010 • achieve by cooperative approach with jurisdictions, all key groups (Panel) and mix of existing and new measures- 8 strategic objectives • eg via safety of roads 19%, vehicle occupant protection 10%, road user behavior 9%, new technology 2%

11. Effective road safety incentives • NRSS 2001-10 & Action Plan Panel- state & territory road/transport bodies- state and territory police- NRTC, Austroads, ALGA - AAA, motorbike, cyclist, pedestrian- insurers (CTP), engineers- research bodies (eg ARRB)- Fed Health Dept, Surgeons, Inst Health - Driver trainers, College of Road Safety- State Schools, Older People Speak Out

12. Effective road safety incentives • Action Plan lists effective measures based on experience, research and data- alcohol in 27% fatal crashes- speed in 24% fatal crashes: casualty crash risk in 60km/h doubles each 5km/h- despite 95% seatbelt wearing, 30% of occupant fatalities are unbelted- 5% drivers and 19% motorcyclists in fatal crashes are unlicenced

13. Effective road safety incentives • Enforcement very important • Education also central (research-based campaigns) • General road improvements reduce fatalities by 2 pa for each $100m • Black Spot program 3 years prevented 32 fatal crashes and 1500 serious crashes for a little over $100m (14:1 BCR) • Safety of work-related road use (OH&S)

14. Effective road safety incentives • ATSB role ‘honest broker’ to monitor progress and revise Action Plans • Administers Black Spot program- based on state/local nominations • Statistics (monthly road toll) & analysis • Research and states’ use (drinking, speed, school buses, fatigue, bullbars) • Vehicle defects and recall ‘incentive’ • Mainly quality of ATSB work/people

15. ATSB Investigations • independent, ‘no-blame’, professional and systemic investigations of accidents, incidents and unsafe situations (eg Avgas contamination, QF1 Bangkok, Bunga Teratai Satu, Ararat) • non-binding recommendations address safety deficiencies identified through investigations to prevent recurrence or worse accidents (safety action is encouraged ahead of final report) • reporting publicly without fear or favour in hard copy reports and via web site www.atsb.gov.au

16. International basis for investigations • Australia has signed up to obligations under international agreements that are incorporated in domestic legislation- Annex 13 to the Conventional on International Civil Aviation outlines the ICAO requirements for aviation accident & incident investigation plus data base - Article 94(7) of UN Convention on the Law of the Sea & IMO marine equivalents

17. International basis for investigations • Annex 13 states at clause 5.4 that:“the accident authority shall have independence in the conduct of the investigation and have unrestricted authority over its conduct”Clause 3.1:“the sole purpose of the investigation of an accident or incident shall be the prevention of accidents and incidents … not to apportion blame or liability.” • Clause 5.6:“the investigator shall have unhampered access to the wreckage and all relevant material & unrestricted control over it”

18. International basis for investigations • Clause 5.12 relates to non disclosure of:- statements taken from persons by investigation authorities (no self incrimination) - all communications between persons involved in operation of aircraft - cockpit voice recordings and transcripts - opinions expressed in analysis of information. • Disclosure may be possible for judicial purposes if the need for disclosure outweighs the possible adverse domestic and international impact on that or any future investigations.

19. Constitutional basis for action • Commonwealth powers vary by mode:- aviation is comprehensive (all ATC, RPT, GA, )- marine does not normally include fishing & recreation vessels (just international/interstate)- rail includes interstate track and the broader related interstate system (growing since 1990s)- road/pipeline can be based on interstate trade, corporations, territories & tied grants powers • ATSB investigations reflect powers:- aviation all sectors incl. QF, AsA, CASA, GA- marine large vessels, rail invitation/legislation

20. Investigation Analysis • In all transport modes analysis important • Assessing factual material including operational, mechanical, structural, replay/analysis voice and data recorders • For example, technical engine analysis.

21. Engine

22. Crankshaft

23. Fracture

24. Fracture

25. Human Factors are central HF 60-100% of accidents & incidents (definitional)- operator and system models and analysis Slips, oops, it happened as I wasn’t thinkingLapses, I forgotMistakes, I thought about it and correctly did the wrong thing (together these are errors) Violations, I deliberately did not follow the laid down procedure (not always malicious) Ergonomics, job design, training, medical, SHELL model (Frank Hawkins, 1987)...

26. Reason ‘Swiss cheese’ system model of accident causation Some holes due to active failures Hazards Other holes due to latent conditions Accident

27. Defences HOW? Losses Hazards How and why defences fail Latent condition pathways Causes Unsafe acts Investigation Local workplace factors WHY? Organisational factors

28. Errors are like mosquitoes: you can swat them one by one but they just keep coming. The best way is to drain the swamps in which they breed Conflicting goals Poor defences Training deficiencies Bad planning Inadequate procedures

29. Deficiencies in training & selection or inexperience? Diminishing culpability 90% 10% Decision tree Knowingly violating safe operating procedures? Pass substitution test? History of unsafe acts? Were the actions as intended? Unauthorised substance? NO NO NO YES NO YES YES NO YES NO YES Were procedures available, workable intelligible and correct? Medical condition? Blameless error Blameless error but corrective training or counselling indicated NO YES Were the consequences as intended? YES NO System- induced error NO YES Possible negligent error System- induced violation YES Possible reckless violation Substance abuse with mitigation Substance abuse without mitigation Sabotage, malevolent damage, suicide, etc.

30. Safe system/Safety culture • ‘No Blame’ reporting and law based on the 90%. • But Just - a clear line between the acceptable and unacceptable, the 10% not tolerated. • Informed - Managers know what’s really going on and workforce is willing to report own errors/near misses. • Wary - Ready for the unexpected. • Flexible - Operates according to need. • Learning - Willing to adapt and implement necessary reforms. • Error tolerant - Lots of defences, robust.

31. Source: Partick Hudson

32. ATSB investigation & analysis • Minor investigations based on technical expertise and getting facts right • More complex investigations include the role of human factors at operator level • Most complex include organisational factors and regulatory environment- culture, budget pressures, ...

33. Aviation Investigation

34. Aviation Investigation • Annex 13 independent investigation • Safety regulator CASA may be a part of the investigation so need separation • Service provider Airservices has monopoly - independent look important • Commercial, change & other pressures increasing, eg post-Ansett Qantas market share, regional operator losses: need for independent investigation

35. Mandatory Aviation Notifications 2000/2001 • Accidents - 216 • Incidents - 5911 • Uncategorised - 1598 • Category 1 to 4 Investigated - 132 • Category 5 not Investigated - 5995

36. Basic Investigation • On-site or “office” • Gathering of evidence • Analysis of evidence- may include tech analysis, HF, weather • draft to ‘interested parties’ • Production/dissemination of report with necessary safety action/recommendation • Many occurrences repeat old problems

37. Weight and balance

38. Weight and balance

39. Aviation Investigation • ATSB focuses investigations where most safety value • Fatalities (power lines, fuel exhaustion, IFR) may warrant less than incidents • No ‘major’ aviation accident, biggest TAA F27 involved 29 fatalities in 1960 • Training in overseas major accident investigations to be prepared- eg currently assisting with S006 Taipei.

40. SQ006, Taipei, October 2000

41. Types Of Investigation • Investigation of- Accidents- Incidents- Systems • Issue Of Safety Concern- Accident/Incident Trends- Fuel Contamination

42. ATSB Recommendations • Objectives are • to increase awareness of hazards • prevent repeat accidents/incidents • ATSB makes safety recommendations • would prefer to be able to report proactive safety actions taken • this happens when there is a mature safety culture.

43. QF1 - Bangkok • Aircraft ran off end of runway • Complex investigation • many factors, human and organisational • Qantas participated as an interested party in the investigation • Were proactive • safety actions taken as problems identified.

44. QF1 Bangkok, September 1999

45. Mobil - Avgas contamination • 3,000 GA aircraft grounded via fuel gunk • Mobil risk & operational processes poor • Could have been Jet A1 fuel • No complete international standards • No effective Australian regulation • Unlike QF, Mobil not pro-active • Significant change internationally via ATSB recommendations

46. Confidential reporting • The CAIR (confidential aviation incident report) program estab in 1988 to supplement mandatory accident/incident reporting • Crew/ATC etc can report if fear sanctions • Confidential not anonymous, & checked • Over 350 reports pa leading to 6 alert bulletins and about 200 info briefs • Low cost and a useful safety net.

47. Safety program - INDICATE • The INDICATE (Identifying Needed Defences In the Civil Aviation Transport Environment) program was initially developed to enable aviation operators improve safety mngt. • It provides a structured framework to evaluate and improve safety including identifying and reporting on weaknesses • Trialed in a regional airline (1998 BASI) • Subsequently used in other modes (CD and ATSB web site)

48. Marine Investigation

49. Effective marine safety incentives • Like aviation, based on independent investigation and recommendations • Human factors important (eg accidents in early am, desensitising to alerts) • Bunga Teratai Satu grounding on GBR- first mate violation (phone to Karachi)- but defences could have been better re crew marking chart, Reefcentre alerts • Common topics fires, lifeboats, cargo, collisions with trawlers

50. Rail Investigation