Transcript Risk - Australian Transport Safety Bureau

NOHSC Effective Incentives Forum
Melbourne, 16 October 2001
“Effective safety incentives
in road, air, marine and rail”
Kym Bills, Executive Director ATSB
Australian Transport
Safety Bureau (ATSB)
An operationally independent Bureau
within the Commonwealth Department
of Transport and Regional Services
- Exec Director statutory powers but
accountability to Sec/Minister eg for
PS Act & FMA Act purposes
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.
ATSB Objective
SAFE
TRANSPORT
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
ATSB Mission
• safety research and data analysis
• safety communication and
education, and
• safety programs, including the cost
effective treatment of road safety
black spots.
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
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
Road safety trends
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%
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
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
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)
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
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
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
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”
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.
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
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.
Engine
Crankshaft
Fracture
Fracture
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 thinking
Lapses, I forgot
Mistakes, 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)...
Reason ‘Swiss cheese’ system
model of accident causation
Some holes due
to active failures
Accident
Hazards
Other holes due to
latent conditions
How and why defences fail
Defences
HOW?
Losses
Hazards
Latent
condition
pathways
WHY?
Unsafe acts
Local workplace factors
Organisational factors
Causes
Investigation
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
Decision tree
Were the
actions
as intended?
NO
Unauthorised
substance?
Knowingly
violating
safe operating
procedures?
NO
Pass
substitution
test?
NO
YES
History
of unsafe
acts?
NO
YES
YES
YES
YES
NO
Were procedures
available, workable
intelligible and
correct?
Medical
condition?
Were the
consequences
as intended?
NO
YES
NO
Substance
abuse without
mitigation
Substance
abuse with
mitigation
Possible
reckless
violation
10%
YES
NO
YES
YES
Sabotage,
malevolent
damage,
suicide, etc.
Deficiencies
in training &
selection or
inexperience?
Systeminduced
violation
Possible
negligent
error
Diminishing
culpability
90%
Systeminduced
error
Blameless
error but
corrective
training or
counselling
indicated
NO
Blameless
error
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.
Safety Culture
GENERATIVE
Increasing
informedness
Safe ty is h ow we do
b usin ess rou nd here.
PROACTIVE
We work o n t he p ro ble ms
th at we st ill fin d
CALCULATIVE
We h ave syste ms in place t o
m anag e all hazard s.
REACTIVE
Safe ty is im po rt ant , we do a lot
every t ime we ha ve an acc iden t.
PATHOLOGICAL
Who cares as lo ng as we’re no t
cau gh t.
Source: Partick Hudson
Increasing
Trust
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, ...
Aviation Investigation
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
Mandatory Aviation Notifications
2000/2001
• Accidents • Incidents • Uncategorised -
216
5911
1598
• Category 1 to 4 Investigated - 132
• Category 5 not Investigated - 5995
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
Weight and balance
Weight and balance
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.
SQ006, Taipei, October 2000
Types Of Investigation
• Investigation of
- Accidents
- Incidents
- Systems
• Issue Of Safety Concern
- Accident/Incident Trends
- Fuel Contamination
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.
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.
QF1 Bangkok, September 1999
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
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.
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)
Marine Investigation
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
Rail Investigation
Effective rail safety incentives
• Picture of Black Mt Qld accident July ‘01
• Rail state-based & engineering/blame
- poor comparable data, few independent
‘no blame’ investigations
• System risk via major change
- structural separation, commercial
pressure, privatisation, greater interstate
• ATSB working on data, system (Ararat),
and legislation re interstate investigation
• Also confidential reporting goal.
Investigations conclusion
• Independent “No Blame” investigations
do mitigate risk
• Complements the regulators audit role
• Complements operators’ safety
management systems
• Technical, operational, human
performance and organisational
investigation are necessary to achieve a
complete understanding
Investigations conclusion
• Important to communicate the results of
investigations & recommendations well
• ATSB does pretty well with the major
reports but could do better with others
• Target audience - looking to develop a
range of more accessible overview
publications & attend more industry fora
• Trade-off with this (and better evaluation)
and doing less investigations
Some overall conclusions
• Road safety effective incentives based on broad
coalition with common purpose and wide range
of data-based measures
• ‘No blame’ independent investigations get to
root causes & lead to appropriate safety action
or recommendations (air, marine, rail)
• Mandatory reporting of safety data can also lead
to trend analysis & targeted recommendations
• Confidential occurrence reporting safety net
• INDICATE type programs and communication of
the safety message also key to effectiveness