The Australian Transport Safety Bureau (ATSB) is an independent Commonwealth Government statutory Agency. The ATSB is governed by a Commission and is entirely separate from transport policy makers, industry operators, and from transport regulators such as the Civil Aviation Safety Authority (CASA).
The ATSB's function is to improve safety and public confidence in the aviation, marine and rail modes of transport through excellence in:
- independent investigation of transport accidents and other safety occurrences
- safety data recording, analysis and research
- fostering safety awareness, knowledge and action.
In the aviation transport mode, the ATSB conduct 'no blame' aviation safety investigations in accordance with the Transport Safety Investigation Act 2003 (TSI Act). The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. Annex 13 (Aircraft Accident and Incident Investigation) to the Convention on International Civil Aviation (Chicago Convention 1944) prescribes international principles for aircraft accident and incident investigation, and the provisions of the TSI Act are designed to reflect those principles.
Does the ATSB investigate all aviation accidents?
The ATSB's primary focus is the safety of the travelling public. Accidents and the most 'serious incidents', as defined by Annex 13, have priority for investigation. The ATSB investigates selectively, as do many equivalent organisations overseas. The aim is to concentrate ATSB's resources on those investigations considered most likely to enhance aviation safety. Because many accidents are repetitive in nature, investigating these in any detail may not be justified, given the ATSB's limited resources. In such cases, the ATSB will not necessarily attend the scene, conduct an in-depth investigation or produce an extensive report.
When the ATSB investigates an accident or incident, investigators will seek to determine its circumstances, identify any safety issues, and encourage relevant safety action. The aim of all ATSB investigations is to prevent the occurrence of other accidents and incidents, rather than to assign blame or liability. This approach helps ensure the continued free flow of safety information for the purposes of improving safety in the future.
Reporting accidents and incidents
As required under the Transport Safety Investigation Regulations 2021 (TSI Regulations), the owner, operator or crew of an aircraft must report an accident or serious incident to the ATSB as soon as practicable and by the quickest means possible. While both the crew and the owner must report the occurrence immediately, it is understood that the owner may not learn of the accident until some time after the event, and that the crew may be unable to notify the ATSB due to personal injuries.
Anyone else learning of an aviation accident should, in addition to alerting emergency services as required, report the accident to the ATSB immediately. While the ATSB does not investigate all accidents and incidents, it still needs to be notified of all aviation occurrences so that the information can be used in future safety research and analysis. Please call the toll-free number 1800 011 034 to notify the ATSB.
Refer to the TSI Regulations for a list of all reportable occurrences and responsible persons who are required to report them to the ATSB. Note that as of 30 September 2021, the TSI Regulations include definitions for Remotely Piloted Aircraft (RPAs), including types which qualify for mandatory reporting under for certain occurrences.
The ATSB operates Australia's REPCON Scheme which offers people in the aviation industry the opportunity to report unsafe conditions, practices or procedures involving aircraft without fear of being identified. For more information about REPCON phone 1800 020 505 or e-mail firstname.lastname@example.org
On receiving a report of an accident or serious incident, the ATSB will decide what action to take. Depending on the type and severity, this may be:
- an on-site investigation carried out by investigators
- a request for more information from an owner, employer or other party
- an entry of accident or incident details into the ATSB's database.
On-site investigations are detailed investigations where investigators travel to the site of the accident. ATSB investigators are responsible for the wreckage and the site's safety when control of the site is handed over to the ATSB after emergency services have declared that it is safe. The investigators photograph and record all the evidence on the ground or associated with the wreckage of the aircraft, and later examine the aircraft's logbooks and maintenance records. They may then arrange for the aircraft wreckage, components and other material evidence to be transported to the ATSB's Canberra office, or some other secure area, for further examination and testing. Consistent with international practices, it is accepted protocol for ATSB investigators to seek information or assistance in a manner that encourages cooperation and the ATSB will liaise with other parties who have an interest.
Wreckage not required for examination by the ATSB, or other investigating organisations with a right to it, is the responsibility of the owner, the owner's estate or the aircraft insurers. Personal effects not relevant to the investigation will be handed to the police for safe custody.
To reconstruct the sequence of events preceding the accident, ATSB investigators will, where necessary, interview the pilot, passengers and other witnesses. They may also visit the departure and destination airfields and interview the pilot's acquaintances and officials, including air traffic controllers, who may have been in contact with the pilot either during or before the flight. They will generally ask for records relating to the pilot's training and experience, and may require company documents relating to the aircraft's operation. They will also require data concerning airfield operations if the accident occurred during the takeoff, approach or landing phase of flight. Maintenance records and interviews with maintenance personnel may also be required.
Investigators will sometimes need to interview the pilot's next of kin to understand the pilot's background, and to examine professional documents or certificates kept at home. This is often an emotional time and investigators always contact the families before visiting. Such meetings allow the next-of-kin to meet the investigators personally, and to discuss the expected progress of the investigation.
Sensitive evidence collected in the course of an investigation is classified as restricted information under the provisions of the TSI Act. The Act contains provisions, which prevent this restricted information from being made freely available for purposes other than transport safety. Importantly, this includes self-incrimination immunity for persons who are required to attend before the ATSB under powers of the TSI Act. Information provided under these circumstances cannot be used against the person in criminal or civil proceedings. Information that is obtained in the course of the investigation including from directly involved parties may be disclosed in the ATSB report. The ATSB will remove information that directly identifies an individual (i.e. names and addresses). However, other indirect identifiers (i.e. times, dates and locations for the occurrence of incidents) will usually be disclosed in the interests of safety. In some situations an individual's position may need to be stated so that reports make sense and safety lessons can be learned by others.
When an ATSB investigation is undertaken, a report is completed for public release. Investigation reports can take many months to produce. It may be necessary to interview numerous individuals, cross-check evidence, examine suspect equipment and consult other technical experts. That can include overseas investigation agencies, regulators, and manufacturers. Often the safety factors identified by the investigation turn out to be very different from the explanations proposed in the media immediately after the event.
The ATSB will send a draft copy of the report to directly involved parties or their representatives. Those parties include individuals or organisations whose reputations may be adversely affected by the report. Under the TSI Act, recipients are required not to copy or disclose the contents of the draft report except for the purpose of providing comments to the ATSB on the draft report, or to take safety action. They will normally have at least several weeks to respond before the report is finalised.
Directly involved individuals and organisations will receive an advance copy of the final report. ATSB investigation report's are released on the ATSB website at www.atsb.gov.au.
ATSB investigation reports and most evidence collected during an investigation cannot be used in civil or criminal proceedings. ATSB investigation reports may be used in coronial inquiries for the purpose of improving safety.
'Safety action' is the term used to describe any action taken by organisations and individuals in response to the safety issues that were identified during an investigation. The aim of any safety action is to prevent similar accidents and incidents.
The ATSB facilitates safety action by communicating the identified safety issues to the relevant organisations throughout the course of an investigation. The ATSB encourages proactive safety action and will acknowledge such action in its investigation reports.
Formal safety recommendations are normally issued when other attempts to facilitate safety action have been unsuccessful, and the risk level is considered by the ATSB to be either critical or significant. The ATSB has no legislative power to enforce its safety recommendations, but it can require a detailed response which may be made public, regarding the implementation of recommendations.
Coronial inquests into an aviation accident
The relevant State or Territory Coroner may hold an inquest into a fatal aviation accident. The Coronial inquest and the ATSB investigation are separate but they do interact.
ATSB investigators may be legally required to appear as expert witnesses. A date for an inquest or inquiry is determined by the Coroner.
The Coroner's Office should be contacted on all matters relating to an inquest. Coronial services can also offer assistance and advice, and some Coronial jurisdictions provide grief counselling and other support for relatives by means of trained professionals.
During the investigation process the ATSB may collect personal information. The ATSB collects personal information for the purposes of investigating transport incidents and accidents. This is authorised by the TSI Act.
The ATSB will use this information for the purposes of the investigation and, subject to the restrictions in the TSI Act may disclose parts of the information to other parties for the purposes of the investigation. The disclosure will also be in accordance with the Australian Privacy Principles under the Privacy Act 1988.
Most personal information held by the ATSB is stored electronically such as on databases, shared drives or in emails, or on hard copy files. The information is held securely and access is limited to ATSB staff that need to access the material to perform their functions.
For more information on the ATSB investigation process.
|Publication date:||28 August 2014|