ATSB Annual Review 2001

Department of Transport and Regional Services Australian Transport Safety Bureau ATSB Annual Review 2001 Published by the Australian Transport Safety Bureau ATSB ANNUAL REVIEW 2001 © Commonwealth of Australia 2001 ISSN 1444-4798 ISBN 0 642 27476 2 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth available from AusInfo. Requests and queries concerning reproduction and rights should be addressed to: The Manager Legislative Services AusInfo GPO Box 1920, Canberra, ACT 2601 Email: [email protected] Address other queries to: The Australian Transport Safety Bureau PO Box 967 Civic Square, ACT 2608 Telephone: 1800 621 372 Fax: 02 6274 6474 Email: [email protected] Design and desktop publishing by David Hope and Lisi Bromley Edited by Paul Porter Photography by Bill Harvey Printed by Union Offset Printers, Fyshwick ACT ii CONTENTS Contents Executive Director’s message 1 ATSB’s mission statement 3 Objective 3 Our mission 3 Our environment and values 3 Our strategy 4 ATSB organisation chart 5 Executive profile 7 Key modal safety activities and results 11 Road 11 Rail 12 Marine 12 Aviation 13 Communications and information 15 Media 15 Web site 16 Information requests 17 Graphic design 17 Investigation reports 18 Freedom of information 18 Human factors course and training 19 Transport industry’s safety performance statistics 21 Multimodal trends (fatalities) 21 Multimodal trends (serious injuries) 24 Data issues 26 Road safety trends 26 Truck safety trends 30 Cost of road accidents 30 Rail safety trends 31 Marine safety trends 32 Aviation safety trends 33 Accidents 34 International comparison 41 iii ATSB ANNUAL REVIEW 2001 Incidents 42 Cost of aviation accidents 44 Modal overviews 45 Road 45 Role 45 Safety programs 45 National Road Safety Strategy and Taskforce 45 Black Spot Program 45 Motor vehicle recall 47 National road safety statistics 48 Road Safety Research Program 49 Heavy vehicle driver fatigue management 50 Speed 50 Road environment 50 Vehicle safety standards 50 Seeding grants 51 Driver-trainer materials 51 Community attitudes 52 Roaduser 52 Participation in Safety Forums 52 Parliamentary inquiries 52 Austroads 52 National Road Safety Strategy Panel 53 Committee to Advise on Recall and Safety 53 Motorcycle Safety Consultative Committee 53 Road Safety Black Spot Program consultative panels 54 Heavy vehicle driver fatigue 54 Fleet safety 54 Rail 54 Role 54 Development of a rail investigation capability 54 Participation in State Government investigations 55 Development of an accident and incident database 56 Participation in safety forums 56 Training for rail industry personnel 57 Research 57 Marine 58 Role 58 Bunga Teratai Satu 59 Padang Hawk 62 iv CONTENTS Ariake 62 Warden Point 63 Small vessel safety 64 Accidents involving ships’ lifeboats 65 Policy and legislation 65 Participation in safety forums 66 Marine Accident Investigators’ International Forum (MAIIF) 66 IMO Flag State Implementation Sub-Committee 67 Maritime training 68 Presentations 68 Aviation 69 Role 69 Occurrence investigations 70 Reduction in investigation backlog 73 Safety deficiency investigations 74 Confidential Aviation Incident Reporting Program 75 Safety promotion 75 INDICATE 76 Presentations at conferences and safety forums 76 Involvement in international cooperation 78 Contributions to Parliamentary inquiries 80 Inquests 80 Internal management and processes 81 Financial overview 81 Risk management 83 People profile 84 Training and development / Investors in People 85 Workforce planning 86 Asset management 86 Access and equity 86 Aboriginal reconciliation 87 Disability strategy 87 Government Online and E-services Initiative 88 Occupational health and safety 88 Output Pricing Review 88 Future plans 91 v ATSB ANNUAL REVIEW 2001 Appendixes 93 Appendix 1: Performance against 2000–01 Portfolio Budget Statements 95 Appendix 2: Statistical, research and investigation reports publicly released in 2000–01 107 Appendix 3: Responses to safety recommendations 114 Appendix 4: Aviation occurrence categories 136 Appendix 5: Aviation safety magazine articles and media notices in 2000–01 137 Appendix 6: Black Spot Program treatments in 2000–01 144 Appendix 7: Contributions to Parliamentary inquiries in 2000–01 156 Appendix 8: Goods and services received by ATSB free of charge 157 Appendix 9: The Gwyn Associates major aviation accident review consultancy 159 Appendix 10: ATSB performance measures in 2001–02 Portfolio Budget Statements 165 Appendix 11: Road safety research grants 2000–01 168 vi EXECUTIVE DIRECTOR’S MESSAGE Executive Director’s message This is ATSB’s second Annual Review and covers the financial year from 1 July 2000 to 30 June 2001, the Bureau’s second year of operation. While not a formal requirement, the Annual Review is prepared to consolidate key safety data and references for the information of our stakeholders and to improve accountability. As detailed in this Review, ATSB had many safety achievements in 2000–01. In road safety, in addition to statistical analysis, research projects, vehicle safety investigation and administering the Federal Black Spot Program, we coordinated Australia’s new National Road Safety Strategy for 2001–10 and the Action Plan for 2001 and 2002. The Strategy was launched by Deputy Prime Minister Anderson and State Ministers in November 2000. In marine safety, a final investigation report was released into the Bunga Teratai Satu grounding, with recommendations made for improving Great Barrier Reef safety. Captain Kit Filor served as chair of the Marine Accident Investigators International Forum. In aviation safety, major reports were released into the Bangkok QF1 747 overrun accident undertaken on behalf of the Thai authorities and into the Avgas contamination that had grounded thousands of smaller aircraft in Australia. ATSB also made important recommendations associated with the Whyalla Airlines accident investigation and the investigation into issues surrounding maintenance problems with Ansett’s 767 fleet. In rail safety, progress was made in developing national best-practice investigation guidelines and in building a national occurrence database. In Canberra, all Bureau staff and our technical analysis facilities were collocated in the refurbished ATSB building at 15 Mort Street. This will further assist the synergies and shared knowledge that were sought when ATSB was established. ATSB actively participated in the output pricing review process coordinated by the Department to meet Finance requirements for all our key outputs to be reviewed and benchmarked before the May 2002 Budget. Key staff departures included two Directors and a Deputy Director. Director Dr Rob Lee, a human factors and air safety international 1 ATSB ANNUAL REVIEW 2001 expert and former long-serving Director of BASI, retired in November 2000, while Director Carol Boughton, who had an international reputation in road safety and several years in aviation safety, retired in January 2001. Deputy Director Barry Sargeant, who had built his reputation with the Monarch 1993 air accident investigation, retired in May 2001. The one-person Sydney office was closed with the retirement of Frank Henry. I gratefully acknowledge the contributions made by Rob, Carol, Barry and Frank, and wish them all well. In January 2001, ATSB was accepted as a member of the International Transportation Safety Association, whose membership includes the chairmen of key multimodal safety bodies such as Canada’s Transportation Safety Board (TSB), the US NTSB, and the Dutch TSB. In 2000–01, the Bureau also made good progress in its preparedness for a major aviation accident investigation. This included participation in a large airport exercise, the conclusion of a consultancy by Gwyn Associates that provided guidance for improvement, establishment of a major accident control centre, improved equipment for investigators, and a five-day major accident management training course by a group of international experts. Because Australia has not had a major air accident since 1968, it is important to prepare, to exercise, and to participate in overseas investigations to the extent that resources allow. For this reason, ATSB assisted with the investigation into the October 2000 SQ006 major 747 accident in Taipei. I acknowledge the support and understanding during the year of our Portfolio Minister, the Hon. John Anderson; Minister in the Senate, the Hon. Ian Macdonald; Parliamentary Secretary, the Hon. Ron Boswell; and Departmental Secretary, Mr Ken Matthews. I am grateful to ATSB’s highly professional and committed staff for the progress we have made in 2000–01 in consolidating as a Bureau and in improving transport safety and look forward to their continuing support in meeting our many challenges in 2001–02. Kym Bills 2 ATSB’S MISSION STATEMENT ATSB’s mission statement Objective Safe transport. Our mission To maintain and improve transport safety and public confidence through excellence in: •open and independent ‘no-blame’ systemic transport accident, incident and safety deficiency investigation; • safety research and data analysis; • safety communication and education; and • safety programs, including the cost-effective treatment of road safety Black Spots. Our environment and values ATSB operates in an environment where transport activity is increasing and the Government, Parliament, media and the public expect increasing standards of transport

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