The Australian Transport Safety Bureau (ATSB) was established under the Transport Safety Investigation Act 2003 (TSI Act) as Australia's national transport safety investigation agency. Its primary function is to improve aviation, marine and rail safety. It does this by receiving information about accidents and other safety occurrences, and by investigating selected occurrences in order to identify and communicate factors that affect, or might affect, transport safety.
The ATSB is part of the Infrastructure and Regional Development portfolio. Within the portfolio are other important transport agencies whose roles are focused on delivering an efficient, sustainable, competitive, safe and secure transport system for all transport users through regulation, financial assistance and safety investigations. These include:
The ATSB is an independent statutory agency of the Australian Government. It is governed by a Commission and is entirely separate from transport regulators, policy makers and service providers. At the same time, it is required to cooperate with others who have a role to play in maintaining and improving transport safety, in particular its counterpart agencies in Victoria and New South Wales.
The ATSB performs its functions in accordance with the provisions of the TSI Act and, where applicable, relevant international agreements. The TSI Act makes it clear that, in carrying out its purpose, the ATSB cannot apportion blame, assist in determining liability or, as a general rule, assist in court proceedings. Its sole focus remains the prevention of future accidents and the improvement of safety.
The ATSB's purpose is to improve the safety of, and public confidence in, aviation, marine and rail transport through:
The ATSB is responsible for investigating accidents and other transport safety matters involving civil aviation, marine and rail operations in Australia, as well as participating in overseas investigations involving Australian-registered aircraft and ships and cooperating more broadly with overseas counterparts. A primary focus of its work is the safety of commercial transport, with particular regard to operations involving the travelling public.
The ATSB maintains a national information set of all safety-related occurrences in aviation and of all accidents and significant safety occurrences in the rail and marine sectors. The information it holds is essential to its capacity to analyse broad safety trends and inform its investigation and safety education work.
The ATSB has a specific mandate to report publicly on its analysis and investigations, and to conduct public education programs so as to improve transport safety.
Since 2014, the ATSB has been undertaking a major underwater search program aimed at locating the missing Malaysia Airlines Flight MH370. This activity has been in support of a Malaysian transport safety investigation into this tragic event.
The ATSB's focus is on improved safety for those who work, or participate, in the various transport industries and for the travelling public. We do this by:
In fulfilling our role of improving transport safety and cooperating with others, the ATSB:
The ATSB works cooperatively with the aviation, marine and rail industries, as well as with transport regulators and governments at state, national and international levels to improve safety standards for all Australians.
The ATSB relies on its ability to build trust and cooperation with the transport industry, and the community, for its success in improving safety. The TSI Act requires the ATSB to cooperate with government agencies, private organisations and individuals who have transport safety functions and responsibilities, or who may be affected by our transport safety activities. The ATSB also cooperates with equivalent national bodies in other countries and international organisations with responsibilities for worldwide transport safety standards.
The ATSB actively targets communications to ensure that transport industry stakeholders understand the importance of no-blame investigations. In order to cultivate a strong reporting culture within the transport industry, the ATSB promotes an appropriate level of confidentiality and protection for sensitive safety information provided to us in the course of our work.
The TSI Act requires any responsible person who has knowledge of any accident (or any immediately reportable matter) to report it as soon as is reasonably practicable.
While the terms of this requirement may seem broad, the Transport Safety Investigation Regulations 2003 provides a list of persons who, by the nature of their qualifications, experience or professional association, would be likely to have knowledge of an immediate or routine reportable matter for their mode of transport. In addition, responsible persons are not required to report a transport safety matter if they believe, on reasonable grounds, that another responsible person has already reported, or is in the process of reporting that matter.
The ATSB maintains a 24-hour service to receive notifications, including a toll-free telephone number (for immediately reportable matters in all modes). In aviation, a secure online notification form for written notifications is available on the ATSB website.
Every year the ATSB's Notifications team receives over 15,000 notifications of safety occurrences. These are spread over aviation, marine and rail. Inevitably, there are duplicate notifications and many of the notifications submitted concern matters not required to be reported under the TSI Act. Nevertheless, each one is reviewed and recorded.
In 2015–16, the ATSB's Notifications team received 16,142 aviation notifications in the form of telephone calls, emails, facsimiles, postal letters and website contact. From those, to date, the team has identified 4,998 individual accidents, serious incidents and incidents for the year.
While not all the reported occurrences are investigated, the details of each occurrence are retained within the ATSB's occurrence database. These records are a valuable resource, providing a detailed portrait of transport safety in Australia. The ATSB regularly analyses the database to identify emerging trends and issues. The searchable public version of the aviation occurrence database is available on the ATSB website. It contains data from July 2003 onwards. The online database is used by industry, scholars, the media, and regulators to search and research past events.
The ATSB investigates accidents and other occurrences involving civil aircraft in Australia. The ATSB also analyses data on all notified accidents and incidents. It conducts research into specific matters of concern that emerge from data analysis and specific incidents or matters that may be referred by other organisations. It does so in a manner consistent with the Convention on International Civil Aviation (Chicago Convention 1944) Aircraft Accident and Incident Investigation (Annex 13).
The ATSB may also investigate serious accidents or incidents involving Australian-registered aircraft overseas, or assist with overseas investigations involving Australian-registered or foreign aircraft if an overseas investigating authority seeks assistance and the ATSB has suitable resources available. The ATSB may also have observer status in important overseas investigations. This provides valuable opportunities to learn from overseas organisations and to benchmark our knowledge and procedures against our sister organisations.
The ATSB cooperates with organisations such as the Civil Aviation Safety Authority (CASA), Airservices Australia and aircraft manufacturers, and operators, who are best placed to improve safety. The ATSB also works collaboratively with the Department of Infrastructure and Regional Development and other safety agencies to assist the government in implementing transport safety initiatives.
The ATSB investigates incidents and accidents involving Australian-registered ships anywhere in the world and foreign ships in Australian waters or en route to Australian ports.
We work cooperatively with international regulatory authorities, Australia's maritime regulator, the Australian Maritime Safety Authority (AMSA), the state and territory maritime regulatory authorities, other transport safety investigation agencies and ship owners and operators.
Our marine investigations are conducted in a manner consistent with the International Maritime Organization Casualty Investigation Code.
We publish a range of marine transport safety reports and safety educational material, which are distributed to the international maritime community, the International Maritime Organization, educational institutions and maritime administrators in Australia and overseas.
Since the implementation of the national transport reform process in January 2013, the ATSB has had primary responsibility for investigating rail safety occurrences (accidents and incidents) on the Defined Interstate Rail Network, regional networks and metropolitan passenger networks in participating states and territories (New South Wales, Victoria, South Australia, Tasmania and the Northern Territory). The ATSB is working to complete the transition to become the national rail safety investigator, as established through the Council of Australian Governments' Intergovernmental Agreement on Rail Safety Regulation and Investigation Reform.
The ATSB works cooperatively with organisations such as the Office of the National Rail Safety Regulator (ONRSR), state and territory rail regulators and rail operators—all of whom share a responsibility to improve safety. The ATSB also has collaboration agreements with the New South Wales and Victorian state safety investigation organisations.
The ATSB Technical Analysis team provides the direct, in-house ability to examine, extract and analyse the physical and recorded evidence associated with safety occurrences from all modes of transport. Nine specialists in forensic engineering, failure analysis, data recovery and systems analysis, work with other ATSB investigators and external stakeholders to provide a detailed insight into the often complex set of factors that underlie many transport safety occurrences. The team maintains a centre of excellence for rail, marine and flight data 'black box' analysis in the South East Asian and Asia-Pacific regions—providing our international neighbours with technical advice, support and assistance in occurrence investigation and capability development.
In addition to its more complex investigations, the ATSB undertakes short, office-based investigations of less complex safety occurrences. Our capacity to conduct a large number of these short investigations provides us with the opportunity to deliver safety messages and for industry participants to learn from the experience of others. Although many of these investigations examine occurrences that are common, and for which the underlying factors are well known, they also enhance the quality and completeness of the occurrence data held by the ATSB. As a result, a more extensive database expands our ability to identify situations where more detailed investigation may be warranted.
A small team manages and processes these investigations and produces short summary reports. The summary reports detail the information gathered from individuals or organisations involved in the occurrence, the circumstances and what safety action may have been taken or identified as a result. The summary reports are released periodically in a bulletin format.
The ATSB operates the voluntary and confidential reporting scheme (REPCON) for the aviation, marine and rail industries. Any person within these industries, or member of the travelling public, may submit a REPCON report of a reportable safety concern. The scheme is designed to capture safety concerns—including unsafe practices, procedures and risk controls within an organisation or affecting part of the industry. The scheme is not about individuals.
Each reported safety concern is de-identified by the ATSB by removing all personal details concerning the reporter and any individual named in the report. This de-identified text is passed back to the reporter who must authorise the content before the REPCON can proceed further. The de-identified text is then forwarded to the relevant organisation that is best placed to address the safety concern. The organisation's response will then be forwarded to the relevant regulator for further action as deemed necessary.
The aim of the REPCON scheme is to ensure safety action is taken to address the reported safety concerns. This can include variations to standards, orders, practices and procedures, or an education campaign. The ATSB may use the de-identified version of the reported safety concern to issue an information brief, or an alert bulletin, to whichever person or organisation is best placed to take safety action in response to the safety concern. The ATSB publishes the outcome of each REPCON on its website.
The Reporting, Short Investigations and Research team researches and analyses the ATSB occurrence databases. In the case of aviation occurrences, the research and analysis provides an opportunity to uncover trends and safety issues across many, rather than individual, occurrences.
Across the transport modes, the team produces official Australian statistics (Aviation Occurrence Statistics, Shipping Occurrence Statistics), and in-depth analysis of issues and trend monitoring of all occurrences for the benefit of government and industry. The research team also contributes to the ATSB's occurrence investigations in all three modes.
The ATSB is not currently funded for research in the marine and rail transport modes.
The ATSB is committed to promoting engagement with its international counterpart agencies and with relevant multilateral organisations. It works to assist Australia's regional neighbours through international agreements and participation in intergovernmental programs. It actively supports initiatives to build aviation and maritime safety investigation capability in the Asia-Pacific region.
The philosophy underpinning the ATSB's regional engagement is one of cooperation and mutual respect. The strategic intent is to improve transport safety for the benefit of our regional neighbours and the Australian travelling public.
Greg Hood was appointed as the second Chief Commissioner of the ATSB on 1 July 2016 for a term of 5 years.
Mr Hood has over 35 years' experience in the aviation industry, culminating in his appointment in October 2013 to the position of Executive General Manager of the Air Traffic Control group with Airservices Australia. In this position he was responsible for the management of over 1,300 air traffic management staff that provide services for 11 per cent of the world's total airspace for over 140 million passengers travelling on more than four million flights annually.
Mr Hood serves on the Business Advisory Council for World Vision, is a Fellow of the Royal Aeronautical Society, a Freeman in the Honourable Company of Air Pilots, a Life Member of the Qantas Founders Museum, and the immediate past President of Canberra Philharmonic Society.
Until being appointed as ATSB's Chief Commissioner, he was also a Board Member of Safeskies Australia and internationally, Vice-Chair of the steering committee for the Civil Air Navigation Services Organisation's (CANSO's) Operations Standing Committee.
Noel Hart has over 40 years' experience in the shipping, oil and gas industries. His qualifications include a Master Mariner Class One qualification, and business administration and MBA certificates.
Mr Hart left his seagoing career to join BP Australia in 1985 and held management positions with BP Shipping in Melbourne, London and Chicago. From 2006 to 2009 he held the position of General Manager of the North West Shelf Shipping Service Company, based in Perth.
In his position he was responsible for the safe shipping of liquefied natural gas from north-western Australia to Asian and other
While based in London, Mr Hart was Chairman of the General Purposes Committee of both the Oil Companies International Marine Forum and the Society of International Gas Tanker and Terminal Operators. He also served as a director of the Middle East Navigational Aids Service, and was an alternate director of the Alaskan Tanker Company and the Marine Preservation Society in the USA, and the Marine Oil Spill Response Centre in Australia.
He has also been Chairman of Maritime Industry Australia Ltd, Australia's peak maritime association, since 2008.
Chris Manning has over 40 years' experience in the aviation industry.
In the early 1970s he was an air traffic controller. From 1975 until 2008 he was a pilot for Qantas.
Captain Manning flew several Boeing types gaining a B767 command in 1989. He was a check and training captain throughout the 1990s, and was president of the Australian and International Pilots' Association from 1999 until 2002.
From 2003 until his retirement from Qantas in 2008, Captain Manning was Chief Pilot and Group General Manager Flight Operations. He chaired the Australian Aviation Associations' Forum from 2008 until 2015. He is a director of Aerospace Australia Limited (Avalon Airshow), is chairman of Airport Coordination Australia and is a founding director of the Australian Aviation Hall of Fame.
Carolyn Walsh has over 30 years' experience in policy development, regulation and safety management at both the Commonwealth and state levels. She has 15 years' experience in the transport sector, initially as Executive Director of Strategy in the NSW Office of the Coordinator-General of Rail, and then as Chief Executive of the NSW Independent Transport Safety and Reliability Regulator.
In addition to her role as a Commissioner of the ATSB, Ms Walsh is currently Deputy Chair of the National Transport Commission and Vice President of Palliative Care NSW. She is also a member of the audit and risk committees for the City of Sydney, NSW Police Integrity Commission, the Aboriginal Lands Council, Western Sydney Local Health District, Office of the Director of Public Prosecutions and NSW Mental Health Commission.
Ms Walsh has specialist expertise in safety (both transport and occupational health and safety), risk management and the regulatory framework governing transport operations in Australia.
Ms Walsh has a Bachelor of Economics degree and is a graduate of the Australian Institute of Company Directors (Company Directors Course).
Peter Foley has held the position of Program Director Operational Search for MH370 since May 2014. He is responsible for the ATSB's operational search activities for missing Malaysia Airlines Flight MH370.
Mr Foley joined the ATSB in 1999 after a career at sea as a marine engineer with Australian shipping companies—including ANL Ltd, the Commonwealth shipping line. Since joining the ATSB he has held a number of roles, most recently as General Manager Surface Safety Investigations. This role included responsibility for marine and rail safety investigations, the ATSB's work on reforms to the National Transport Regulatory framework, and the ATSB's international programs. He has been responsible for performing and managing a large number of marine and rail investigations, many of them significant. He has represented the ATSB, and Australia, at many international marine and rail industry meetings and conferences.
Mr Foley holds professional qualifications in marine engineering and transport safety investigation, degrees in marine and mechanical engineering and a Graduate Diploma in Business Management.
Colin McNamara joined the ATSB as the Manager Learning and Development in October 2004. Prior to this appointment he served as a General Service Officer in the Australian Army and was awarded the Australian Active Service Medal in 1999.
Since joining the ATSB, Mr McNamara's responsibilities have been progressively expanded to include the management of Human Resources, Organisational Development, Governance and Investigator Support. Over the past five years he has also served as the agency's Head of Corporate Services. In this capacity he has been instrumental in the development and implementation of a number of key strategic documents including the Corporate Plan, Workforce Plans and the agency's Enterprise Agreements.
Mr McNamara holds a range of professional qualifications in human resources and is a professional member of the Australian Human Resources Institute.
Peter Robertson joined the ATSB in May 2016. He has been a Commonwealth public servant for over 30 years after training initially in the RAAF as a pilot.
He has worked in a range of Commonwealth departments, primarily in policy and regulatory areas affecting the aviation, maritime, communications and land transport industries, including the Office of Transport Security. Before taking up his current position he was responsible for legal, communications and environmental matters associated with the development of a second major airport for Sydney following a secondment as deputy coordinator in the search for missing airliner MH370. He holds the degrees of Bachelor of Arts and Master of Commerce.
Ian Sangston joined the ATSB as a Senior Transport Safety Investigator (STSI) in April 2002 after 23 years' service in the Australian Defence Force. In addition to a number of pilot qualifications, he has an undergraduate degree and two masters degrees in Management Studies and Employment Relations.
Mr Sangston managed a number of high profile investigations as an STSI, and completed a Diploma of Transport Safety Investigation in June 2005. He was promoted to Team Leader, Transport Safety Investigation in mid–2006 and assumed responsibility for the Perth Regional Office. As team leader he oversaw more than 80 aviation safety investigations. Mr Sangston was promoted to his present position in August 2009 and has been instrumental in the ATSB's development of a project management approach to investigation management.
Programme 1.1 Objective
The ATSB will work actively with the aviation, marine and rail industries, transport regulators and governments at a state, national and international level to improve transport safety standards for all Australians, particularly the travelling public. Investigations and related activities seek to raise awareness of identified safety issues and to encourage stakeholders to implement actions to improve future safety.
There are three core functions which arise from the ATSB's functions under the Transport Safety Investigation Act 2003:
Section 63A of the Transport Safety Investigation Act 2003 (TSI Act) requires that:
The annual report prepared by the Chief Executive Officer and given to the Minister under section 46 of the Public Governance, Performance and Accountability Act 2013 (PGPA Act) for a period must include the following:
The ATSB observes and complies with Resource Management Guide No 135–Annual reports for non-corporate Commonwealth entities issued by the Department of Finance. This report is based on the guidance for 2015–16 published in July 2016.
The ATSB will report performance against the program objectives, deliverables and key performance indicators published in the Infrastructure and Regional Development 2015–16 Portfolio Budget Statements. The ATSB annual report also includes audited financial statements in accordance with the PGPA Act.
PRIORITIES FOR INVESTIGATION
The ATSB's highest priority is to investigate accidents and safety occurrences that have the greatest potential to deliver improved transport safety for the travelling public.
The ATSB is not resourced to investigate every single accident or incident that is reported, but allocates priorities within the transport modes to ensure that investigation effort achieves the best outcomes for safety improvement. The ATSB recognises that there is often more to be learned from serious incidents and patterns of incidents and places some focus on these investigations as well as on specific accident investigations.
THREE WAYS TO ACTION
The TSI Act requires specified people and organisations to report to the ATSB on a range of safety occurrences (called 'reportable matters'). Reportable matters are defined in the Transport Safety Investigation Regulations 2003. In principle, the ATSB can investigate any of these reportable matters. In practice, they are actioned in one of three ways to contribute to the ATSB's functions:
Note: In the third approach, the occurrence is not investigated immediately, but may be the subject of a future safety issue or research investigation.
AVIATION BROAD HIERARCHY
The ATSB allocates its investigation resources in line with the following broad hierarchy of aviation operation types:
The ATSB endeavours to investigate all fatal accidents involving VH-registered powered aircraft subject to the potential transport safety learnings and resource availability.
MARINE BROAD HIERARCHY
The ATSB allocates its investigative resources in line with the following broad hierarchy of marine operation types:
RAIL BROAD HIERARCHY
The ATSB allocates its investigative resources in line with the following hierarchy of rail operation types:
LEVEL OF RESPONSE
The level of investigative response is determined by resource availability and factors such as those detailed below. These factors (expressed in no particular order) may vary in the degree to which they influence the ATSB's decisions to investigate and respond. Factors include:
The objective of the classification process is to quickly identify, allocate resources and appropriately manage occurrences that:
The ATSB's response to reported safety matters is classified by the level of resources and/or complexity and time they require.
The following safety investigation levels are used by the ATSB:
Investigations that are likely to involve, at times, significant ATSB and external resources for up to 24 months and are likely to require additional one-off government funding.
Investigations that are likely to involve a large number of ATSB resources, and possibly external resources, and are of a scale and complexity that usually require up to 18 months to complete.
Investigations involving in-the-field activity, several ATSB and possibly external resources, and are of a scale and complexity that usually requires up to 12 months to complete.
Less complex investigations that require no more than nine months to complete (some of which are 'desktop' exercises requiring no in-field activity) and involve only one or two ATSB staff.
Investigations that are less complex and require no more than five months to complete (in some cases, after initial in-the-field or other investigation activity, the investigation level may be changed or the investigation discontinued if it is determined that there is no safety value to be gained from continuing the investigation). These investigations generally involve only one or two ATSB staff.
Short investigations are limited-scope factual information only investigations that result in a short summary report of one to two pages. Short investigations are generally completed within two months and are usually published in a monthly bulletin. They require only one ATSB staff member.
Note: For the purpose of reporting against the 2015–16 Portfolio Budget Statements performance measures, the ATSB defines its Level 5 investigations as 'less complex'.