ATSB Annual Plan 2014-15

Who we are

The Australian Transport Safety Bureau (ATSB) is established under the Transport Safety Investigation Act 2003 (TSI Act) as the national transport safety investigation agency.

What we do

The TSI Act sets out the role and responsibilities of the ATSB. Our primary role is to improve aviation, marine and rail safety for the travelling public and for those who work or participate in the various transport industries. We do this by:

  • receiving and assessing reports of transport safety matters, including notifications of safety occurrences and confidential reporting
  • independently conducting no blame investigations of accidents and other safety occurrences
  • conducting research into transport statistics and technical issues
  • identifying factors that contributed to accidents and other safety occurrences that affect or have the potential to affect transport safety
  • encouraging safety action in response to safety factors by acknowledging safety action taken by operators and by issuing safety recommendations and advisory notices
  • raising awareness of safety issues by reporting publicly on investigations and conducting educational programs.

The ATSB is independent and operates on a ‘no blame’ basis: it is prevented from apportioning blame or providing the means to determine liability in transport safety matters. The ATSB is also required to cooperate with other parties that have powers relating to transport safety or functions affected by the ATSB's priority of improving transport safety.

In Victoria and New South Wales we work in collaboration with the state rail safety investigation bodies: the Office of the Transport Safety Investigations (NSW) and the Chief Investigator, Transport Safety (Vic). In South Australia and Tasmania our role covers all rail networks. In Queensland and Western Australia we continue to focus on the interstate network until those states finalise their participation in the national rail safety reforms.

Our maritime work remains focussed on larger vessels on international or interstate voyages.

How we do it

While protecting our independence, we work closely with transport safety regulators and the aviation, marine and rail industries. We approach our work in accordance with five key principles intended to maintain trust in our organisation:

Independence: we think for ourselves
Engagement: we work with others
Rigour: we rely on evidence
Innovation: we are open to new ideas
Relevance: we make a difference

To improve transport safety and cooperate with others, we:

  • focus our resources where they are most likely to result in safety improvements
  • harness the expertise and information necessary to our safety role
  • conduct impartial, systemic and timely safety investigations
  • identify safety issues based on evidence and expert analysis
  • report safety issues clearly and objectively, without attributing blame or liability
  • ensure the significance of safety issues is clearly understood by all concerned
  • promote effective safety action.

The ATSB's highest operational priority is to investigate those accidents and safety occurrences that have the greatest potential to deliver improved transport safety, with a particular focus on the safety of the travelling public.

For many occurrences, the contributing factors and safety issues are already well understood and there is unlikely to be any significant safety benefit from an extensive investigation. In those cases, the ATSB may limit itself to a fact-gathering investigation. Equally, there is often as much or more to be learned from serious incidents or patterns of incident as there is from accidents and, where appropriate, the ATSB will give priority to investigating these sorts of safety occurrences.

Why we do it

Independent 'no blame' investigation of transport accidents and other safety occurrences
Independent investigations that are selective and systemic, and which focus on future safety rather than on blame, increase stakeholder awareness of and action on safety issues and foster industry and public confidence in the transport system.

Safety data recording, analysis and research
Timely receipt and assessment of transport accident and other safety occurrence notifications allows the ATSB to identify and refer safety issues at the earliest opportunity. The maintenance and analysis of a body of safety information (including transport safety data and research and investigation reports) enables stakeholders and researchers to gain a better understanding of safety trends and safety issues.

Fostering safety awareness, knowledge and action
Awareness and understanding of transport safety issues is increased through a range of activities including consultation, safety awareness, and the promulgation of research and investigation findings and recommendations. These contribute to the national and international body of safety knowledge and foster action for the improvement of safety systems and operations.

Our priorities for 2014-15

The ATSB determines its priorities by assessing transport industry safety trends, reviewing its own performance as a safety agency and being responsive to the expectations of the Government and the Australian public.

Leading into the 2014-15 financial year, the ATSB has had to reduce staff numbers significantly to ensure that it remains financially sustainable. It is more important than ever that the ATSB optimises use of its people and resources and continues to give priority to those activities that provide the greatest value in safety improvements for transport operators and the travelling public. To achieve this, the ATSB will carefully select what occurrences are investigated and closely manage the scope of each investigation that is selected.

At the same time, the ATSB has been taking an increasing role in the search for the missing Malaysia Airlines Flight MH370 and has been given significant new resources for that purpose. The ATSB will be vigilant of any shifts within its enterprise risk profile as a result of the Australian Government’s commitments to the search for MH370.

Support the Malaysian Government’s investigation into the loss of Malaysia Airlines Flight MH370

We will lead the international effort to locate the missing Malaysia Airlines Flight MH370.

We will determine the priority search area, commission contractors to undertake a bathymetric survey of the search area and coordinate a comprehensive sub-surface search of the area.

We will provide expert assistance to the Malaysian Government’s Annex 13 investigation into the circumstances of the accident involving Malaysia Airlines Flight MH370.

Maintaining capability and effectiveness

We will work to improve the efficiency, effectiveness and timeliness of our investigations.

We will develop and implement new workforce strategies that reflect our constrained resources and draw more extensively on external partnerships.

We will continuously improve our investigation policies and procedures to maintain our status as a best practice safety investigation agency.

We will work collaboratively with government and safety agencies to assist in implementing the outcomes of government and external reviews.

We will monitor our efficiency, effectiveness and timeliness through benchmarking with like agencies

Maintaining stakeholder relationships

The ATSB will engage and cooperate with stakeholders, while protecting our independence. Our three areas of focus are:

  • other safety agencies (including coroners and overseas counterpart agencies);
  • transport industry participants; and
  • the travelling public.

We will continue to interact with other safety agencies by updating and renegotiating our memoranda of understanding and other collaboration mechanisms.

We will continue to engage with industry participants, to promote our investigation findings and safety messages and to ensure feedback on our work.

We will maintain our engagement with the public and industry through targeted use of social media.

Commitment to safety communication and awareness

The ATSB will publish material aimed at operators and others, based on our analysis of occurrence data and our investigation findings.

Through the SafetyWatch initiative, the ATSB will heighten attention on the following risk areas:

  • Avoidable accidents in general aviation
  • Safe work on rail
  • Safety around non-towered aerodromes
  • Maritime pilotage
  • Data input errors in aviation
  • Handling an aircraft’s approach to land
  • Under-reporting of safety occurrences
  • Safer marine work practices
  • Flying in reduced visibility conditions.

Regional and International engagement

We will be an active and constructive player in the International Civil Aviation Organization, the International Maritime Organization and other international and regional forums that have a role in transport safety.

As well as fulfilling our international obligations, we will work cooperatively with regional neighbours to assist them to improve transport safety.

In addition to our assistance to Malaysia with MH370, the ATSB will participate in Australian Government regional transport safety initiatives including the Indonesia Transport Safety Assistance Package (ITSAP) and assist Papua New Guinea consistent with the MOU on Cooperation in the Transport Sector.

Active participation in transport safety reform

We will work towards completing the transition to being the national rail safety investigator, as agreed through the COAG Intergovernmental Agreement on Rail Safety Regulation and Investigation Reform.

We will also work collaboratively with the Department of Infrastructure and Regional Development and safety agencies to assist government in implementing the outcomes of its Aviation Safety Regulation Review and other relevant external reviews.

Sharing safety information

We will work closely with regulators and the Department of Infrastructure and Regional Development to ensure arrangements are in place for the appropriate sharing and use of safety information and that these arrangements are transparent to industry and consistent with a strong reporting culture. 

We will promote public access to transport safety accident and incident occurrence data and our statistical holdings. including through our publicly available and searchable aviation occurrence database.

Focussed safety research and data analysis

We will publish and undertake a research program informed by:

  • analysis of safety data holdings and investigation findings
  • consultation with relevant stakeholders, including other safety agencies, educational institutions and transport industry participants.

We will enhance our safety occurrence trend monitoring capability, including developing occurrence risk ratings to allow indications of safety risk from occurrence data. These trends will be made available to the public via the ATSB’s website.

We will work to improve consistency and comparability of transport safety datasets, including those that focus on the collection, collation and analysis of data.

We will assist the national rail regulator to create a national safety occurrence dataset. We will ensure ready access to the data, and that the databases will be conducive to proactive data analysis for measuring safety within the industry.

Preparedness for a major accident

We will ensure we are prepared for a major accident by reviewing and testing our major accident response and management capabilities.

We will review and evaluate our planning and implementation for a major accident involving an Australian-registered aircraft in the context of our experiences in support of the Malaysian Government’s investigation into Malaysia Airlines Flight MH370.

Our deliverables

The ATSB is funded by the Australian Government to deliver specified activities and services. Our targets in this regard include:

Deliverable: We will coordinate the sub-surface search for Malaysia Airlines Flight MH370 over an area of up to 60,000 square kilometres.

Target: Successful completion of the search of the 60,000 square kilometre area, confirming the location of the aircraft wreckage or determining that the wreckage is not in the search area.


Deliverable: We will assess, classify and publish summaries of all accident and incident occurrences received.

Target: Summaries of occurrences are published within 10 working days of receipt.


Deliverable: We will assess confidential reports for clarity, completeness and significance for transport safety and, where appropriate, advise any responsible party in a position to take safety action in response to the safety concern.

Target: A de-identified summary of the confidential report will be provided to any relevant third party within 5 working days.

Within 2 months, advise a responsible party in a position to take safety action in response to the safety concern.


Deliverable: We will complete and publish research and analysis reports based on safety priorities and trends.

Target: Up to 8 reports as part of an annual research program.

Reports on aviation safety trends provided to the Minister and safety agencies biannually.


Deliverable: We will ensure we are prepared for a major accident by reviewing and testing our major accident response and management capabilities.

Target: Participation in one major exercise per annum.


Deliverable: We will assist regional transport safety through participation in the Indonesian Transport Safety Assistance Package (ITSAP) and cooperation with Papua New Guinea consistent with the Memorandum of Understanding on Cooperation in the Transport Sector.

Target: Delivery of approved projects within Program funding allocation.


Deliverable: We will publish and deliver an annual program of safety communication and awareness.

Target: Implementation of the published program.


Key performance indicators

The following key performance indicators help measure our effectiveness:

Key performance indicator: Safety action is taken by stakeholders to adequately address identified safety issues.

Target: Critical safety Issues: 100%. 
Significant safety issues: 70%.


Key performance indicator: Stakeholders are aware of safety issues raised as a result of investigation, research and analysis findings.

Target: Survey of stakeholders indicates a high level of awareness.

Key performance indicator: Investigation reports are published in a timely manner.

Target: At least 90% of complex investigations published within 12 months.
At least 90% of short investigations published within 2 months.



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Last update 25 February 2020