Is the ATSB the best organisation we have to investigate crashes?

[old man emu]

Well, the request has been made for someone to start a thread to discuss whether or not the ATSB is the best organisation to investigate fatal and injury crashes involving RAA aircraft.

 

Elsewhere I had voiced my opinion that the ATSB's investigation of fatal and injury crashes is secretive, uninformative and not up to the desired standard.

 

I have also voiced the opinion that the ATSB is a financially restricted, insufficiently competent organisation to carry out the important task of gathering and presenting the facts of a crash incident to those authorities charged with determining the causes of deaths arising from aviation crashes, and who have the ability to make recommendations aimed at preventing like incidents in the future.

 

I have voiced the opinion that the specialist Accident Investigation Units of the several State Police Forces are more experienced in investigating crashes involving the various forms of powered transport, and that this experience is readily transferred to the particular needs of an investigation into an aircraft crash.

 

I clarify this opinion by saying that the Police are the best organisations we have to gather facts arising from a crash, but the determination of any culpability lies in the hands of one or more of a Coroner's Court, a Criminal Court, or a Civil Court.

 

Please enter the discussion.

 

Old Man Emu

 

 

[fly_tornado]

The problem with a lot of the crashes, especially the RAA ones, is the cost of the investigation. The most recent crash is an example, looks like the plane went in on a steep angle. How you would determine the cause without spending a bucket of money?

 

 

[Tex]

the determination of any culpability lies in the hands of one or more of a Coroner's Court

One quick point: In Qld Section 28 (1) of the Coroners Act 2003 (Qld) authorises the holding of an inquest into a reportable death if the Coroner considers it desirable to do so. If possible the Coroner is required to find: - Whether a death in fact happened; Identity of the deceased; When, where and how the death occurred; What caused the person to die.

"The focus is on discovering what happened, not on ascribing guilt, attributing blame or apportioning liability. The purpose is to inform the family and the public of how the death occurred with a view of reducing the likelihood of similar deaths. As a result the Act authorises a Coroner to make preventative recommendations concerning public health and safety, the administration of justice or ways to prevent deaths in similar circumstances in the future."

 

 

[motzartmerv]

EMU. As someone said in the other thread, the police perform a parallel investigation.When they pull out of the investigation is once they establish a crime hasn't been committed ( i would suspect).

 

Having recently been heavily involved in one such investigation I saw this first hand. Having to conduct 2 sperate interviews with both the cops and the ATSB.

 

I found both investigations to be absolutely thorough.

 

The interview with the ATSB was more then an hour and a half, and all regarding something that took less then 20 seconds to transpire.

 

While the police have excellent investigation skills, they are not aircraft engineers, ex raaf and airline pilots etc. They are trained to investigate. The ATSB investigator's knew the aircraft involved inside and out.

 

Someone would pick up some seemingly insignificant part off the ground and these guys knew what it was, where it came from, and where it was suposed to be.

 

That being said, the head of the police investigation team was also a very experienced aviator, and I have to say, a very interesting guy.

 

To be of benefit to anyone, the investigation needs to be thorough. It is a painstaking and meticulous process. Its no good putting a statement out in a weeks time about what they reckon caused the crash if its totally wrong.

 

In the accident Im referring to, the investigators have video evidence and 6 pilots as very close witnesses. The probable cause was apparent straight away, but, to be thorough, they need to rule everything else out before they

 

go and release the findings. What we all think happend may have happend, but been totally unrelated to what brought the aircraft down. Now if they just packed up and went home, and said "pilot error" and not done anything else, a very grave and serious problem may have been overlooked. And that could potentially COST lives.

 

After the incident at Jaspers, a patch of dead grass in the area the choppa was parked seemed to grow in size over the next week.. I contacted the ATSB, they looked at pictures and saw that a patch of dead grass was evident on the day. But to be sure, they sent forensic guys back to the scene, at quite a cost no doubt, to take soil samples etc. They did that even though they have a video of the accident. They have evidence that points to ONE possible cause.

 

I dont see any issue with the way investigations are carried out. WHEN THEY ARE CARRIED OUT. And this is the problem I think alot of us in the RAA feel, that RAA aircraft accidents should be investigated just as thourughly

 

by the same guys.

 

But sprewking on the forum isn't going to help that. What can be done?..How can we make a change? Id be more than happy to throw effort into the cause if i knew where to direct it.

 

Anyone got any ideas?. We need problem solvers, not just problem identifiers.

 

 

[Tex]

When they pull out of the investigation is once they establish a crime hasn't been committed ( i would suspect).

No MM they will continue to carry on with the investigation and report to the Coroner under his/her responsibilities as stated above (s28 Coroners Act 2003 (Qld))

 

But sprewking on the forum isn't going to help that. What can be done?..How can we make a change? Id be more than happy to throw effort into the cause if i knew where to direct it.

Anyone got any ideas?. We need problem solvers, not just problem identifiers.

That is a very astute observation... read a few Coroners' Reports and they lament the very same thing... even their recommendations more often than not, (if ever) are not acted upon in aviation accidents RE CASA and ATSB (thankfully so though in some cases)... which takes us back to the whole Cth v State issue...

 

 

[old man emu]

Cost, Cost, Cost!

 

Yes, any investigation involves cost, and as our analytical techniques multiply, costs rise. And let's look at an investigation as a team effort.

 

Say we are investigating a fatal incident. The Coroner has the ultimate responsibility for the investigation. The Coroner may, and for practical reasons does, delegate the investigation to the State Police. A Lead Police Investigator is appointed to lead the investigation, and that person delegates tasks to a number of other specialists, be it photographers, mapping specialists, aviation experts (like parachute packers in the case of a parachuting incident), airframe and systems experts, chemists, metallurgists etc, etc. The Lead Police Investigator then collates all the factual information for presentation at a Coronial Inquest. There the facts are subject to scrutiny and argument until the Coroner is in a position to make a finding. From then on, the Criminal and Civil jurisdictions may or may not have a run, using the facts brought out by the investigation. Nobody said that an accident investigation should be done and dusted in a week or two.

 

What we should be protesting is the failure of the ATSB to be open with its findings, and for CASA to stop being a timid mouse when it comes to enforcing the Laws of this country.

 

As far as I am concerned, I wouldn't entrust the ATSB to investigate a crash of crockery. And I have been a Lead Police Investigator on a couple of aviation fatalities.

 

Old Man Emu

 

 

[motzartmerv]

So your suggesting that the police should investigate all crashes? And we get rid of the atsb?

 

Were you with the aviation fatalities section of the police?

 

Why do you think the atsb are not open with their findings? I'm not disagreeing, I wouldn't know.

 

 

[old man emu]

Motz,

 

At one time I was THE Accident Reconstructionist for the NSW Police. That was after completing studies in the USA, and receiving certification there as a Traffic Accident Reconstructionist. Due to internal politics, the standards of the current NSW Police Accident Investigation Squad are just coming up to par with those of Victoria and Queensland.

 

I was involved in the investigation of a fatal crash at Camden several years ago (the Victa with the woman pilot). The ATSB came, investigated, and sat on their findings. Since I was the Investigation Leader, reporting to the State Coroner, I expected to get a statement of findings from the ATSB to include in my report. No such luck!

 

As a result, the Coroner originally made a finding that the crash was accidental, the fault laying with the pilot. That finding was made without a formal Inquest. By the way, my enquiries did not lead me to the opinion that any other person was culpable in the death as it was a matter of fuel exhaustion, and everyone knows that the pilot has the final responsibility for the fuel load on board.

 

Naturally, the family was not happy with that finding and pushed for a full inquest. The matter was reinvestigated by local detectives (I was retired by then). I don't know the final result.

 

Following the initial decision of the Deputy State Coroner, I discussed with him the need for the Police to establish a Police Aviation Fatality Liaison Officer to assist local police in the investigation of aviation fatalities in their Patrols. Because I have been out of the Police Force for nearly six years now, I don't know if that position has been created. Something similar seems to exist in Queensland.

 

The investigation of a death is the responsibility of the Coroner, and if the Coroner wants something done as part of that investigation, it gets done. Therefore, if the investigators want to engage an expert (such as a LAME who has good experience with some facet of the airplane involved in the incident) all they have to do is ask the Coroner to direct that the expert be engaged to carry out and report on the necessary investigation. The cost then come out of the Police Force's Special Investigations budget.

 

OK. That's support for my argument that Police should investigate all aviation serious or fatal incidents, just as they do for road and water transport.

 

Should we get rid of the ATSB? I can't think of a good reason to say yeah or nay. Don't forget that the ATSB's area of interest covers ALL transport accidents. Since rail and sea transport accidents are rare, it is probably contacted more frequently about aviation accidents. The ATSB is more interested in public transport than private transport.

 

Why are ATSB investigations a closed book? Well they shouldn't be. Any material produced by a servant of the government in the course of their duties is public domain, unless it affects national security. They say that the role of the ATSB does not cover the laying of blame. I agree. That is the role of the Justice system. However, the ATSB is an investigative branch of the Government, and its investigation reports and investigators should be open to scrutiny in the Justice system.

 

The real fly in the ointment is CASA. Unlike the US of A's FAA whose charter is to promote aviation, CASA's charter is to promote aviation safety. Its record in that field is appalling. Our elected representatives (all parties) have made laws and regulations for aviation in this country. Included in those laws and regulations are penalties for breaking them. CASA has a woeful record of prosecuting breaches, no matter how blatant they are. CASA is like Ferdinand, the bull with the delicate ego, who would rather sit and smell flowers than fight a matador as he was bred to do.

 

Old Man Emu

 

 

[motzartmerv]

That's very interesting EMU. When you say that the atsb didn't provide you with a report on their findings, was One given to the coroner at all from them? Did they do a report at all? It's strange if they didn't.

 

The nsw police do have an aviation fatalities branch now.

 

After the accident at jaspers they arrived in pol air within about 45 minutes.

 

Can you tell us why the ATSB don't investigate raa fatal accidents? I've sen the legislative document describing when they should and by my limited understanding I can't see why raa is precluded.

 

If it is only a cost related decision I'm gunna start slapping sOme pollies.

 

 

[old man emu]

I think that there was some documentation given to the Coroner, but getting it was like pulling teeth. Since I was not involved in an open hearing, I don't know what the Coroner saw.

 

I'm glad that the NSW Police have moved ahead in this area.

 

I can't say why the ATSB stays away from most RAA incidents. As I said, CASA is charged with promoting aviation safety, ergo so its agencies should be interested. I'd say that it's all financial.

 

Looks like yo got some bitch slappin' to be doing, dude.

 

Old Man Emu

 

 

[motzartmerv]

Oooooooo. It's on. CASA Andy carpark now.

 

 

[dutchroll]

Motz,I was involved in the investigation of a fatal crash at Camden several years ago (the Victa with the woman pilot). The ATSB came, investigated, and sat on their findings. Since I was the Investigation Leader, reporting to the State Coroner, I expected to get a statement of findings from the ATSB to include in my report. No such luck!

At that point had they only completed the draft report (rather than the final)? Because a draft report is not admissible in evidence to any court (including the coroner). They are allowed to show selected persons a draft report, but disclosure of a draft report to a court by anyone is punishable by 2 years imprisonment under the Transport Safety Investigation Act. Not saying you weren't aware of this, but just pointing it out in case.

 

That report took a long while to release in final form. I'm not excusing the delay, but if they only had a draft at the time when the coroner did his report, then the legislation is pretty clear.

 

I think anyone not totally familiar with the Act might be pretty surprised at what the ATSB are not allowed to tell people until the final report is approved. And to be honest, that's not their fault. Just putting this out there, that's all.

 

For what it's worth, I think they (the ATSB) do a pretty good job. There is no public investigation bureau anywhere in the world (including the police) which is resourced enough to investigate everything all the time and have a final report out whenever anyone wants it.

 

 

[old man emu]

disclosure of a draft report to a court by anyone is punishable by 2 years imprisonment under the Transport Safety Investigation Act.

what the ATSB are not allowed to tell people until the final report is approved.

To me, that provides the ATSB with an excuse for sitting on an investigation, and for political interference in the approval of the report.

 

For what it's worth, I think they (the ATSB) do a pretty good job. There is no public investigation bureau anywhere in the world (including the police) which is resourced enough to investigate everything all the time and have a final report out whenever anyone wants it.

I'm sorry, but I cannot agree with you. The ATSB says that it does the best investigations. I don't believe that it has the numbers of investigations to back this up. Police (and here I refer to specialist accident investigators) are doing more investigations in greater detail each year than does the ATSB. Further, Police are required to complete these investigations in a timely manner. If the Investigating officer is dragging the chain, the kicks in the bum start from the State Coroner and work their way down.

 

Police have access to the same range of experts as the ATSB to have technical investigations carried out. And since police are working to a deadline, they see to it that things get done. The ATSB investigators aren't gods. In fact some of them don't have as much experience as people who make a living maintaining and using airplanes.

 

Perhaps the best thing to do would be to disband the ATSB investigations section, but provide it with the results of professional forensic investigations, and from those results the ATSB can produce its draft reports for the Minister.

 

Old Man Emu

 

 

[dutchroll]

Actually the effect is opposite. Because their reports cannot be used as evidence, it frees them from the possibility of interference from any party, especially the politics of threatening legal action/consequences. It's just the law, and it's made very clear in the Act. This allows them the time to thoroughly investigate all possible aspects without such external pressures.

 

In other words, the ATSB doesn't have to worry about the influence or ramifications of "person X" or "authority Y" coming up to them and saying "you better hurry up and get that report done because we're gonna use it to take legal action" or "we're thinking of charging the pilot with manslaughter" or any other such pressure which might influence the way the report is compiled.

 

While I have great respect for the police in general (and their investigation skills), as a pilot, I would rather have the ATSB investigating any aviation accident I was involved in than the police, knowing I can tell them exactly what happened without feeling I'm being investigated myself, and knowing that what I say during the investigation won't make it straight into the hands of an all-too-clever lawyer or into a court transcript. That is how the Act and Regs are designed.

 

I actually know a very experienced former RAAF accident investigator. He has a very interesting story of the civil police trying to get involved in an aircraft accident investigation, interfering with the accident site in a way that could compromise the investigation, and eventually having to threaten to have them detained by the military police if they didn't leave.

 

 

[old man emu]

As I said earlier, I was able to suggest to the State Coroner for NSW that an Aviation Accident Investigation Officer be appointed to liaise with local police investigating a fatal air incident. That suggestion was made nearly 10 years ago. Since then, it appears that the suggestion was acted upon by several Police Forces and there are now Police Accident Investigators trained to deal with aviation incidents. That story from the RAAF investigator could well have been true back in the day. Now police have been instructed in crime scene preservation, and I doubt if that sort of thing would be permitted nowadays.

 

You clearly do not understand the legal process if you think that Police lay charges in such serious matters as manslaughter without having checked the evidence thoroughly. That's why there is a Coroner's Inquest. The evidence is examined by a Court and the Coroner can decide whether or not some person has a case to answer or not, and whether a jury, properly instructed, is likely to return a verdict. (Note I said "verdict", not "guilty verdict" or even "not guilty verdict". In other words, the evidence it sufficient for a jury to make a firm decision.)

 

And what special skills does the ATSB bring to an investigation? I'm not a LAME, but I know what to look for in logbooks, fuel records, aircraft useage records etc. I can engage a highly experienced engine or airframe engineer, metallurgist, avionics technician etc to examine an airplane. As for statements from involved parties, well, years of police investigations have taught me when to recognise that I am being given a load of crap. If I was to caution a person about self-incimination, I'd still get 90% of the story that I could accept as valid. The physical evidence would give me the other 10%. As a matter of fact, I found that interviewing people who might have committed and offence, and victims as well, was often a necessary formality as their versions often did not tally with the physical evidence.

 

My opinion is that the ATSB try bluff and bluster to stand over Police in these investigations, and their final product does little to advance air safety.

 

I think that the ATSB is as useless as a fob pocket in a pair of budgie smugglers.

 

Old Man Emu

 

 

[dutchroll]

OK then. No probs.

 

I'm not going to pursue this debate into a full on d*ck-swinging contest. However making statements about the ATSB like "their final product does little to advance air safety" is a tad broad-brushed and over the top, if you ask my opinion (and I'm volunteering it even if you don't want it).

 

And I'm certain that police always check the evidence thoroughly before laying charges. It's just an unfortunate fact of life that they don't turn out to be right 100% of the time.

 

 

[Guest ozzie]

I think what we have to look at here first is just what part each 'body' play in the investigation and the process of each in the timeline. IE from 000 call to coroner.

 

GA aircraft goes in with fatalities.. 000 operator receives call. Police and services respond. Police take charge and secure site. Now what happens from here? When does the ATSB step in? Do CASA get involved? Who releases bodies and wreck and into whose charge do they go? What do the police investigate? If any air law has been broken doesn't CASA lay the charges? And what if any charges can the police lay if say pilot survives and pax deceased. Can the Police/CASA use any info from ATSB report to lay charges?

 

Police ATSB and CASA all report to Coroner?

 

RAAus aircraft goes in with fatalities. Pretty much same Qs with the addition of when and if the RAAus get involved in lue of CASA? Their powers or limitations? Report if any recognised by Coroner? As stated earlier it seems the ATSB will only get involved if public attention is drawn to accident or circumstance. So is it all left up to the police only?

 

Ozzie

 

 

[old man emu]

Dutchroll,

 

I will fight to the death to preserve your right to your opinion. Both being gentlemen, I think we can agree to disagree, and that will be the end of it. You are an ATSB supporter, I am not. That having been said, it looks like we will have to discuss ways to reach a middle ground.

 

When does the ATSB step in?

They are advised by Police ASAP

 

Do CASA get involved?

I believe quite late in the process

 

Who releases bodies and into whose charge do they go?

ATSB advise local police that the bodies can be released (taken away) from the accident site because the ATSB has recorded sufficient evidence involving them at the scene. From the moment of death, the body is in the charge of the State Coroner. The ATSB say when the wreckage can be released (removed from the scene). After it leaves the scene, the chain of possession of evidence becomes a bit murky. The ATSB doesn't have secure premises to hold complete aircraft, so they are often just stuck in the back of some convenient hangar. the ATSB will remove components for examination, but they don't retain them thereafter. They are usually returned to the custody of the Investigating Police Officer.

 

What do the police investigate?

The Police investigation carried out on behalf of the Coroner aims to identify the deceased; the time, date, and place of death, and if the circumstances of the death suggest that living person/s did, or omitted to do, any act that could have lead to the death.

 

If any air law has been broken doesn't CASA lay the charges?

Yes. CASA approves the laying of charges, but if charges were laid, it would be the Investigating Police Officer who would act as the Informant, and charges would be laid under Commonwealth Law, which State Police are permitted to do.

 

And what if any charges can the police lay if say pilot survives and pax deceased.

CASA only control the laying of charges for breaches of the Federal legislation relation to aviation. Based on the evidence obtained, State Police could lay charges ranging from murder to "by negligent act cause actual bodily harm". In other words, virtually the whole gamut of the Assault offences. Why don't they? Because historically there has not been the legal experience within the Police Forces to overcome Society's impression that airplane are inherently unsafe, and will crash without warning, and that if you fly in anything other than on an RPT service, you are taking your life into your own hands. I would hope that now that more experienced police investigators are looking at serious and fatal aviation incidents, they State Police will begin to prosecute those whose actions on the ground, or in the air lead to untimely deaths.

 

Can the Police/CASA use any info from ATSB report to lay charges?

Yes, but only after the ATSB report has been approved by someone in the ATSB who has the authority to do so.

 

Police, ATSB and CASA all report to Coroner?

Yes; Yes and not necessarily.

 

RAAus aircraft goes in with fatalities. Pretty much same Qs

Not sure, but I would assume the answers are the same.

with the addition of when and if the RAAus get involved in lue of CASA?

It would seem that RAAus gets involved when the ATSB says it is not interested.

 

Their powers or limitations?

The assistance of the RAAus would be received with open arms by any wise Police Investigator.

 

Report if any recognised by Coroner?

The Coroner will accept all evidence placed before the Court, and consider its value in light of the qualifications and techniques used by the witness in gathering information given as evidence.

 

As stated earlier it seems the ATSB will only get involved if public attention is drawn to accident or circumstance. So is it all left up to the police only? Ozzie

Yep.Old Man Emu

 

 

[Guest ozzie]

Thanks for that. Interesting how it all works. Now all we have to do is get them to release the information in a reasonable time frame.

 

I wonder what would happen if there was a number of fatalities/accidents in close succession that could all be linked to a common cause that could have been prevented if the ATSB had released the information from the first accident in the string in a reasonable time to prevent the others from occurring. IE a structural failure or engine problem.

 

Could the ATSB be held liable or are they above reproach?

 

Ozzie

 

 

[djpacro]

..... if there was a number of fatalities/accidents in close succession that could all be linked to a common cause ...

- potential technical issues are generally identified quite early (one of the important questions that other operators are keen to ask after an accident - hence the reason for some discussion on the forum) and addressed by CASA (with an AD) or the manufacturer (with a SB etc) etc in a timely manner. (I can remember one accident where with CASA's co-operation I had a SB and a supporting AD out within 36 hours of an accident.)Otherwise there are not very many new ways for "pilot error" - use of a fancy new electronic device may be a new factor these days but otherwise the statistics seem fairly stable as to the causes of accidents - us pilots need regular reminders of what can kill us and how to minimise the risks.

 

That's why CASA publishes their Flight Safety Australia magazine - free copy mailed to anyone of you who wants it.

 

 

[fly_tornado]

this months sport aviation has some interesting articles on accidents http://www.sportaviationonline.org/sportaviation/201204#pg32