How ATSB safety investigation
reports are organised
ATSB investigation reports are organised in accordance with
international standards or instruments, as applicable, and with
ATSB procedures and guidelines. Reports normally contain the
following main parts:
Part 1: Factual information
Provides objective information that is pertinent to the
understanding of the circumstances surrounding the occurrence
Part 2: Analysis
Discusses and evaluates the factual information presented in Part
1 that the ATSB considered when determining its findings and safety
actions.
Part 3: Findings
Based on the analysis of the factual information, presents three
categories of findings; contributing safety factors; other safety
factors; and other key findings.
Part 4: Safety action
Based on the findings of the investigation, records the main local
actions already taken or being taken by the stakeholders involved,
and recommends safety actions required to be taken to eliminate or
mitigate safety issues.
Part 5: Appendixes
Contains additional information that supports the report, for
example, specialist reports on materials failure or flight data
analysis.
Note: Not all parts described above will be
applicable in all circumstances. Reports of less complex
investigations, for example, may not include safety action or
appendixes.
Terminology
used in ATSB safety investigation reports
Occurrence: accident or incident.
Safety factor: an event or condition that
increases safety risk. In other words, it is something that, if it
occurred in the future, would increase the likelihood of an
occurrence, and/or the severity of the adverse consequences
associated with an occurrence. Safety factors include the
occurrence events (e.g. engine failure, signal passed at danger,
grounding), individual actions (e.g. errors and violations), local
conditions, risk controls and organisational influences.
Contributing safety factor: a safety factor
that, if it had not occurred or existed at the relevant time, then
either: (a) the occurrence would probably not have occurred; or (b)
the adverse consequences associated with the occurrence would
probably not have occurred or have been as serious, or (c) another
contributing safety factor would probably not have occurred or
existed.
Other safety factor: a safety factor identified
during an occurrence investigation which did not meet the
definition of contributing safety factor but was still considered
to be important to communicate in an investigation report.
Other key finding: any finding, other than that
associated with safety factors, considered important to include in
an investigation report. Such findings may resolve ambiguity or
controversy, describe possible scenarios or safety factors when
firm safety factor findings were not able to be made, or note
events or conditions which 'saved the day' or played an important
role in reducing the risk associated with an occurrence.
Safety issue: a safety factor that (a) can
reasonably be regarded as having the potential to adversely affect
the safety of future operations, and (b) is a characteristic of an
organisation or a system, rather than a characteristic of a
specific individual, or characteristic of an operational
environment at a specific point in time.
Safety issues can broadly be classified in terms of their level
of risk as follows:
Critical safety issue: associated with an
intolerable level of risk.
Significant safety issue: associated with a
risk level regarded as acceptable only if it is kept as low as
reasonably practicable.
Minor safety issue: associated with a broadly
acceptable level of risk.