Investigating Critical Risk Incidents Presented by Kym Bills, Chair, AIHS College of Fellows 2019 Victorian Safety Symposium

1. Investigating Critical Risk Incidents
Kym Bills, Chair AIHS College of Fellows & Chair AIHS SA Branch
Overview
• What are critical risk incidents?
• When and why should they be investigated?
• What problems can arise with investigations?
• Example of a good practice ATSB aviation fatal accident investigation
• Do Quinlan’s 10 Pathways shed light on this accident’s critical risks?
• Conclusions and Further Reading

2. What are critical risk incidents?
• I am using a broad definition of ‘critical risk incidents’ to encompass
accidents and other ‘near-miss’ high potential occurrences that do or
could lead to fatalities, serious injuries and major economic impacts
- they therefore meet the ‘mission critical’ Symposium theme test.
• Most here know that careful consideration of risks and hazards and
design and implementation of controls is a key focus, particularly in high
hazard industries like mining, oil and gas, aviation and nuclear power.
• For all businesses, regulatory legislation and guidance, and standards
like ISO 45001 can help guide implementation.
• When a major accident occurs, it typically is multi-factorial and involves a
break down of controls with respect to critical risks. It may be an accident
involving fatalities and from which the business will not recover and may
be subject to multiple external investigations, including as to criminality.
• It is important to find and include near-miss critical risk incidents that
could otherwise be serious accidents because learning from them may
well avoid a future accident and ensure the survival of the business.

3. When and why should we investigate critical risk incidents?
• When a reportable accident or incident occurs it normally needs to be
investigated in-house. The relevant regulator and possibly an
independent investigator like the ATSB may also choose to investigate.
• In addition to ensuring their legal obligations, WHS-focussed businesses
have good internal communication and reporting processes that
encourage the reporting of concerns around critical risks that are then
addressed, possibly by an investigation process scaled for the size of
business and potential severity of the concern or incident.
• Why an investigation should be undertaken is to look at the whole
context of a system that led to the accident or near-miss and seek to find
and address any significant safety issues found (not just causal factors).
• An investigation seeks to establish what happened, how it happened and
why it happened. Mostly the why is not because of an error or mistake by
a lazy or capricious worker who failed to follow detailed written
procedures. Human performance factors and real work context need to
be understood and the whole system examined and challenged.

4. What problems can arise with investigations?
• There are many good investigations - and funding limits even the best.
• For greater insight, I called 40-year industry practitioner, Peter Wilkinson,
who said “common problems include overdoing investigation of non-
critical incidents, people finding what they look for when investigating,
and not making assumptions clear, including in investigation models”
- some assume worker fault, others inevitably point to managers.
• When organisations investigate their own critical risk incidents, outcome
quality is dependent on organisational culture, maturity and resources as
well as the capability and objectivity of the investigator/s
- managers and workers who fear blame and retribution are unlikely to be
forthcoming or may just be blinded by the surprise of the incident.
• Larger businesses may ‘lawyer up’ and investigate under the cloak of
legal professional privilege. This is rarely the best way to encourage full
disclosure of what, how and why it happened and to learn and address
safety lessons internally (let alone promulgating them to relevant others).

5. ATSB investigations are generally well regarded but had difficult
moments involving regulators & coronial inquests

6. Good practice ATSB independent aviation investigation
• Just after 1143 on 7 May 2005, Metro 23 aircraft VH-TFU hit a mountain
11km short of its intended runway killing all 13 passengers and 2 crew
• It was an instrument flight rules (IFR) regular public transport (RPT)
service from Bamaga near the Torres Strait to Cairns with a scheduled
stop at Lockhart River
• The aircraft was destroyed by the impact and subsequent fire. Both black
boxes were recovered: FDR data ok; CVR inoperative last 30 mins flight
• Experienced pilot-in-command (PIC 40yo) likely handling pilot and also
base manager of inexperienced (21yo) co-pilot who was not endorsed for
the type of satellite navigation approach proposed and was not assertive
• PIC knew weather bad at Lockhart River, had a history of flying fast and
breaking rules: liked to be on time and was due at Lockhart River at 1140
• High trans-cockpit authority gradient and neither pilot had previously
demonstrated a high level of crew resource management skills
• Lost situational awareness, possible ‘shooting for the hole’ etc - CFIT.

8. Individual
Actions
Local
Conditions
Risk
Controls
Organisational
Influences
Transair chief
pilot commitment
to safety
Transair
organisational
structure
Descent
problems not
corrected
Descent below
segment minimum
safe altitude
Controlled flight
into terrain
Loss of
situational
awareness
Common
practices of pilot
in command
High workload
Pilot training
Pilot checking
Conducting RNAV
(GNSS) approach when
copilot not endorsed
Descent speeds, approach
speeds and rate of descent
exceeded
Transair risk
management
processes
CRM conditionsCopilot ability for
the RNAV (GNSS)
approaches
Crew
endorsements
and clearance
to line
Supervision of
flight operations
Operations
manual SOPs
for approaches
Operations
manual
useability
Approach chart
design issues
Cockpit layout
RNAV
approach
waypoint
names
CASA guidelines
for inspectors
CASA processes
for accepting
approaches
Consistency with
CASA oversight
requirements
CASA processes
for evaluating
operations manual
Regulatory
requirements
TAWS not
fitted
GPWS on
normal
approaches
CASA AOC
approval
processes
Runway 12
RNAV (GNSS)
approach design
Regulatory
Oversight CASA airline
risk profiles
Collision with Terrain
11 km NW Lockhart River Aerodrome
7 May 2005
VH-TFU, SA227-DC

9. Do Quinlan’s 10 Pathways shed light on this accident’s critical risks?
1. Design, engineering and maintenance flaws
CVR inoperative; no enhanced GPWS (alert overload); Runway 12 GNSS
approach design; Jeppesen chart
2. Failure to heed clear warning signals
PIC surprised by high terrain 10 days before; advised weather poor & PIC
thought may not be able to land yet fast and unstabilised approach in IFR;
de-sensitised to GPWS alerts and high workload
3. Flaws in risk assessment
Lockhart River approaches not risk assessed; Transair incremental growth
from small freight charter service to 40 pilot multi-state & aircraft type -
limited risk assessment by company or by the regulator (CASA)
4. Flaws in management systems & changes to work organisation
Chief Pilot overloaded (MD and PNG); SMS Ops Manual Word docs on a
disk; Open book exams; safety reports not actioned; No MOC re expansion
5. Flaws in system auditing and monitoring
No Transair analysis of past flights too fast/steep; CASA lack of follow-up
especially when operator seen as high risk from 2004

10. Do Quinlan’s 10 Pathways shed light on this accident’s critical risks?
6. Economic/production and rewards pressures compromising safety
Management resources almost absent - Chief Pilot/MD/PNG little interest in
safety. PIC trying to make up time to be on schedule. Unendorsed pilots etc
7. Failures in regulatory oversight
CASA inspector training; Transair incremental AOC expansion to high risk
8. Supervisor and worker expressed concerns prior to the incident
Worker and other copilot concerns re PIC; safety reports not seen as
important by Chief Pilot/MD and actioned so often not made at all
9. Poor management/worker communication/trust
Issues between assertive and intolerant PIC/manager and co-pilot; Chief
Pilot/MD little time for communication and no safety priority, so no trust
10. Flaws in emergency procedures and resources
Not at issue given the almost total destruction of the aircraft and instant
deaths of all on board. The ATSB investigation team had to fell trees to land
a helicopter and clear a path to the accident site on South Pap. Transair’s
procedures and resources were almost uniformly sub-optimal.

11. Conclusions
• After the accident, Transair surrendered its AOC and went out of
business. The relatives and friends of those who died still suffer.
• This type of detailed independent investigation is the exception not the
rule but can uncover safety issues beyond just the workers
• Even with best intentions, in-house investigations can lack capability and
objectivity - if an incident is serious enough, consider professional help
even if it is to review what an in-house team has found
• Don’t waste time and money unnecessarily investigating non-critical risks
- just repair the stair tread or ensure PPE is up to scratch
• Decluttering requires a laser-like focus on procedures addressing critical
risks and controls with workers consulted about their real work context
• Protect workers and others; be realistic about safety/production/profit
trade-offs and work-as-done versus as-imagined or in policy edicts
• Design out and control your critical risks and ensure there is a good ‘no
blame’ reporting culture so action can be taken before an accident
• Consider Quinlan’s 10 pathways before you have a disastrous incident.

12. Further Reading
For those who want to better understand the Lockhart River accident the
media release and audio of my media conference plus a link to the final
report is available here: https://www.atsb.gov.au/newsroom/2007/release/2007_18/
There was also a subsequent Coronial inquest and report:
https://www.courts.qld.gov.au/__data/assets/pdf_file/0003/86682/cif-lockhart-river-aircrash-20070817.pdf
Professor Michael Quinlan’s 2014 book is: Ten Pathways to Death and Disaster:
Learning from Fatal Incidents in Mines and other High Hazard Workplaces
The OHS Body of Knowledge, stewarded by the AIHS is available free on-
line and chapters 12.3 by Trish Kerin and 34.1 by Leo Ruschena are
particularly relevant on risk controls: http://www.ohsbok.org.au/download-the-body-of-knowledge/
Peter Wilkinson of Noetic is a wise and experienced practitioner on critical
risk controls, see pages 7-11 at: https://www.aihs.org.au/sites/default/files/Sep17OHSFinal.pdf
Many authors have written on critical risk safety investigations and I
commend the works of James Reason, Andrew Hopkins and Sidney Dekker
Todd Conklin’s 2012 book Pre-accident Investigations is well worth a read
on dealing with incident investigations that don’t advance safety outcomes.