[Peetwo]

A recent article in the Adelaide Advertiser is titled '649 days after plane tragedy, fiancee still seeks answers'. I think that speaks for itself!

As the widow of one of the pilots killed I have maintained a high level of interest in this investigation. The ATSB have made it quite clear that outside involvement is most unwelcome on every level. At the beginning of this investigation I was free to communicate directly with the investigator in charge however he resigned, effective immediately, in April 2018. Since then, despite repeated requests, ATSB have resolutely refused to allow us to know the name of the person investigating this accident. Why should this be the case? Surely, having lost so much, I am entitled to know who is investigating the crash which left a little boy without his Daddy?

http://web.mit.edu/~alo/www/Papers/ntsb17.pdf

Perhaps ATSB should be looking at the NTSB model?

CG - "Perhaps ATSB should be looking at the NTSB model?

Spend a little time - HERE - withe the ANAO report into ATSB. The devil in in the detail.

In follow up to the "K" link please refer: ANAO wet lettuce report? - Not a good look for the Hooded Canary.

And from the "Government News" blog: https://www.governmentnews.com.au/nation...g-mid-air/

TRANSPORT Judy Skatssoon

Transport safety investigations stall

14 March, 2019



The ATSB is getting less efficient at investigating accidents and incidents, an audit has found.


The national transport safety agency is getting less efficient at investigating accidents and safety incidents as it  battles to reduce a backlog of cases, an audit has found.

The time taken and resources needed by the Australian Transport Safety Bureau (ATSB) to complete investigations “have increased significantly over the last five years,” according to a  report  by the Australian National Audit Office  (ANAO) tabled on Thursday.

“The efficiency with which the ATSB investigates transport accidents and safety occurrences has been declining … both in relation to the length of time taken to complete investigations, and the amount of investigation resources required,” it found.

The report found that the time taken on “short” investigations increased from an average of 131 days before 2018 to 236 days over the first six months of that year. “Complex” investigations meanwhile were taking nearly three years to complete in the first half of 2018 – more than twice as long as  in 2016.

The ANAO recommended that the ATSB does more to ensure short investigations are completed quickly, reviews its use of resources and sets more realistic investigation deadlines.

The report also notes that the reputation of the agency took a hit after it was criticised for a three year delay in investigating the ditching of an aircraft carrying a seriously ill patient off Norfolk Island in 2009, when it was forced to reopen the investigation after pressure from a senate inquiry.

“Although the Aviation Safety Regulation Review 2014 stated this was an ‘aberration’ and not typical of the high standard that the ATSB usually attains, this had a negative impact on the ATSB’s reputation,” the report states.
In 2017-18, 6,350 incidents came under consideration for investigation by the ATSB and by November last year it had 122 ongoing investigations. Since then, the agency has attempted to reduce the number of ongoing investigations and take on fewer new ones.

The auditor’s office said the ATSB receives an average of more than 15,000 notifications of incidents and accidents a year but the trend has been steadily increasing since 2010. It noted that Australia hasn’t experienced “a major catastrophic event” that has required a major investigation.

Improving efficiency

The ATSB has acknowledged the findings and says it was already working to improve efficiency before the audit, and has since been applying a project management approach to investigations.

“The ATSB will soon release a varied corporate plan with more suitable key performance indicators for timeliness and demand/capacity,” it added.

Funding for the ATSB, a Commonwealth body established in 2003 to improve safety and public confidence in air, sea and rail transportation, was increased by $11.9 million over five years in the 2017 budget to boost its workforce and meet technical and data needs.

And from the ANAO report itself, too which GN refers:

What controls does the ATSB have in place to assure itself that improvements in efficiency do not compromise the quality of its investigations?

The ATSB has had quality controls and processes in place, however they have not been conducive to the timely completion and review of investigations. Since 2017, the ATSB has implemented key review points earlier in the investigations process. As a result, the ATSB has identified improvements in quality and a reduction in the amount of rework required through the various review stages.

2.50 The ATSB was criticised for its investigation report into the 2009 ditching of an aircraft off Norfolk Island17, due to its delay (nearly three years after the accident) plus the lack of detailed analysis and useful recommendations for avoiding future incidents and accidents. Although the Aviation Safety Regulation Review 2014 stated this was an ‘aberration’ and not typical of the high standard that the ATSB usually attains, this had a negative impact on the ATSB’s reputation. Similarly, the December 2014 peer review report of the ATSB’s investigation methodologies and processes18 conducted by the Transportation Safety Board of Canada concluded that, when the ATSB methodology is adhered to, and the component tools and processes to challenge and strengthen analysis are applied, the investigation result is more defensible.

2.51 The ATSB has identified that its workflow processes have not been conducive to the timely completion and review of investigations and associated safety activities. The workflow processes incorporated high levels of quality control during the draft report review phase, but contained limited quality assurance measures within the earlier investigation phases.19 In May 2017, in an Executive Paper, the ATSB acknowledged that its own investigation workflow processes and practices had directly contributed to its output timeliness issues, principally due to extensive review and rework requirements which were necessary to ensure that a quality report was released.

2.52 Since the broader organisational change initiatives in 2017, and in particular through the SIRF project, there have been major changes to the workflow processes for ATSB investigations. This has seen the increase in controls within the review process where there are multiple layers of review to gain the required level of quality assurance to release an investigation report. The improved workflow process for stages of an investigation currently include:

• planning meetings to ensure appropriate scope and resources;
  
  
• required analysis processes;
  
  
• safety factor reviews with managers and directors;
  
  
• safety factor executive briefs;
  
  
• technical review of reports;
  
  
• administrative reviews;
  
  
• director reviews;
  
  
• Commission reviews; and
  
  
• external reviews.
  
  
  

2.53 The ATSB advised the ANAO in October 2018 that since these processes have been introduced, and although in the early stages of implementation and application to current investigations, there has been notable improvements in quality and a reduction in the amount of rework required through the various review stages.

2.54 The ATSB further advised the ANAO in October 2018 that it is committed to looking for improvements across the range of investigatory processes and practices to improve efficiency, transparency and to better enable management decisions. As part of the work being undertaken to introduce a program managed approach to investigations, there is also a planned focus on strengthening the assurance processes that support the investigation process. For example, the ATSB is planning to establish an Investigation Review Board to more closely manage quality, risk mitigation and delivery issues.

"..Similarly, the December 2014 peer review report of the ATSB’s investigation methodologies and processes18 conducted by the Transportation Safety Board of Canada concluded that, when the ATSB methodology is adhered to, and the component tools and processes to challenge and strengthen analysis are applied, the investigation result is more defensible..."

TSBC peer review references: PelAir - 'Lest we forget' Part III & [b]How things have changed? NOT!  [/b]

In December this year will mark five years since the TSBC peer review report and recommendations were released for public consumption: http://www.bst-tsb.gc.ca/eng/coll/2014/A...141201.asp 

Recommendations
The TSB Review is making 14 recommendations to the ATSB in four main areas:

• Ensuring the consistent application of existing methodologies and processes
  
  
• Improving investigation methodologies and processes where they were found to have deficiencies
  
  
• Improving the oversight and governance of investigations
  
  
• Managing communications challenges more effectively.
  

Recommendation #1: Given that the ATSB investigation methodology and analysis tools represent best practice and have been shown to produce very good results, the ATSB should continue efforts to ensure the consistent application and use of its methodology and tools.
Recommendation #2: The ATSB should consider adding mechanisms to its review process to ensure there is a response to each comment made by a reviewer, and that there is a second-level review to verify that the response addresses the comment adequately.
Recommendation #3: The ATSB should augment its DIP process to ensure the Commission is satisfied that each comment has been adequately addressed, and that a response describing actions taken by the ATSB is provided to the person who submitted it.
Recommendation #4: The ATSB should review its risk assessment methodology and the use of risk labels to ensure that risks are appropriately described, and that the use of the labels is not diverting attention away from mitigating the unsafe conditions identified in the investigation.
Recommendation #5: The ATSB should review its investigation schedules for the completion of various levels of investigation to ensure that realistic timelines are communicated to stakeholders.
Recommendation #6: The ATSB should take steps to ensure that a systematic, iterative, team approach to analysis is used in all investigations.
Recommendation #7: The ATSB should provide investigators with a specific tool to assist with the collection and analysis of data in the area of sleep-related fatigue.
Recommendation #8: The ATSB should review the quality assurance measures adopted by the new team leaders and incorporate them in SIQS to ensure that their continued use is not dependent on the initiative of specific individuals.
Recommendation #9: The ATSB should modify the Commission report review process so that the Commission sees the report at a point in the investigation when deficiencies can be addressed, and the Commission's feedback is clearly communicated to staff and systematically addressed.
Recommendation #10: The ATSB should undertake a review of the structure, role, and responsibilities of its Commission with a view to ensuring clearer accountability for timely and effective oversight of the ATSB's investigations and reports.
Recommendation #11: The ATSB should adjust the critical investigation review procedures to ensure that the process for making and documenting decisions about investigation scope and direction is clearly communicated and consistently applied.
Recommendation #12: The ATSB should take steps to ensure closure briefings are conducted for all investigations.
Recommendation #13: The ATSB should provide clear guidance to all investigators that emphasizes both the independence of ATSB investigations, regardless of any regulatory investigations or audits being conducted at the same time, and the importance of collecting data related to regulatory oversight as a matter of course.
Recommendation #14: The ATSB should implement a process to ensure that communications staff identify any issues or controversy that might arise when a report is released, and develop a suitable communications plan to address them.

Much like the Hooded Canary's commitment (pic above) to address the ANAO recommendations, Beaker made similar commitment to address the TSBC recommendations. However the overwhelming evidence from the ANAO report and the handling of several high profile investigations since (including the Rossair investigation), would point towards blatant disregard and mere lipservice by the HC's regime in regard to independent and peer review findings/recommendations. So why should industry stakeholders and the many concerned DIPs/NOK put any faith in the hollow words of the Hooded Canary et.al in promising to address properly and transparently the ANAO recommendations and DIP/NOK concerns?

MTF...P2