Report on performance

This section reviews the ATSB's results against the performance criteria and deliverables set out in the Portfolio Budget Statements 2015–16 and ATSB Corporate Plan 2015–16. The ATSB's effectiveness in achieving planned outcomes during 2015–16 is also reviewed here.

Annual performance statement

I, as the accountable authority of the Australian Transport Safety Bureau, present the annual performance statement of the Australian Transport Safety Bureau for the year ended 30 June 2016, as required under paragraph 39(1)(a) of the Public Governance, Performance and Accountability Act 2013 (PGPA Act). In my opinion, this annual performance statement is based on properly maintained records, accurately reflects the performance of the entity, and complies with subsection 39(2) of the PGPA Act.

signature of greg

Greg Hood
Chief Executive Officer

4 October 2016

Table 1: Results against performance criteria


As set out in the Portfolio Budget Statements 2015–16 and the ATSB Corporate Plan 2015–16, the ATSB's purpose is to improve the safety of, and public confidence in, aviation, marine and rail transport through:

  • independent 'no-blame' investigation of transport accidents and other safety occurrences
  • safety data recording, analysis and research
  • fostering safety awareness, knowledge and action.

Performance criterion

Safety actions completed that address 100% of critical safety issues identified by ATSB investigation reports.


No critical safety issues were identified in 2015–16.

Performance criterion

Safety actions completed that address 70% of all other safety issues identified by ATSB investigation reports.


68% of all other safety issues identified by ATSB investigation reports were addressed in 2015–16.

Performance criterion

90% of complex investigation reports are published within 12 months.


29% of complex investigation reports were published within 12 months during 2015–16.

Performance criterion

90% of short investigation reports are completed within two months.


31% of short investigation reports were completed within two months during 2015–16.

Performance criterion

Stakeholder awareness of safety issues is raised as a result of investigation, research and analysis of findings; and through safety education activities as measured through a biennial survey, scoring a rating of 5 or above based on a 7-point rating scale. Note, this rating scale was revised to a 5-point scale during 2015–16 and therefore a new target rating of 4 or above was set.


A rating of 4 was achieved through the 2015–16 stakeholder awareness survey.

Performance criterion

70% of safety action is taken by stakeholders to address valid safety concerns identified by confidential reports.


52% of safety action was undertaken by stakeholders to address safety concerns identified by confidential reports.

Analysis of performance

The ATSB operates in an environment of continuing growth and emerging trends across the aviation, rail and marine transport sectors. In contrast, the ATSB has been subjected to successive reductions to its base appropriations with further reductions projected over its forward estimates. This has resulted in a reduction in the ATSB's core capabilities (staffing profile including specialist investigators) by about 25 per cent since its establishment as an independent statutory authority in July 2009.

The ATSB has continued to meet its key deliverables in terms of the number of investigation reports completed and published per year. However, it is evident the ATSB has not been able to complete these reports within the set timeframes. While the number of deliverables has been maintained, with fewer investigators having to take on greater workloads, completion times have been delayed. To address this situation, the ATSB will initially undertake fewer investigations and will need to carefully consider and constrain the scope of investigations initiated. Concurrently, the ATSB will strengthen its investigation management techniques for planning investigations, assigning resources and tracking resource commitment. By maturing its investigation management practices, ATSB investigators will be better positioned to apply developed project management skills capable of achieving a defined outcome, with agreed resources within a prescribed time period.

Further, the ATSB will also need to enhance its data-driven approach to transport safety through increasing its capacity to carefully analyse available occurrence data. This will enable the ATSB to selectively allocate its limited resources towards investigating those accidents and incidents that will have the greatest potential for safety learnings and enhancement. It will also expand the ATSB's capacity to identify emerging threats to transport safety.

Performance at a glance website Links

Table 2: Performance at a glance 1




Per cent completed

Complex investigations

Per cent completed
within 12 months































Short investigations

Per cent completed
within 2 months

All modes










Key results website Links

Table 3 summarises the ATSB's performance against key indicators published in the 2015–16 Portfolio Budget Statements.

Table 3: ATSB performance against key indicators 2




Key Performance Indicators

Safety actions completed that address safety issues identified by ATSB investigation reports:

  • Critical safety issues
  • All other safety issues

100% addressed

70% addressed

None identified

68% addressed2


Complex investigation reports are published within 12 months.

90% published within 12 months.



Short investigation reports are completed within two months.

90% completed within two months.



Stakeholder awareness is raised as a result of investigation, research and analysis of findings and through safety education activities as measured through a biennial survey, scored on a five point rating scale.

Rating of 4 or above.



Safety action is taken by stakeholders to address valid safety concerns identified by confidential reports.

70% actioned




Assess, classify and publish summaries of accident and incident occurrences received.

Details of occurrences being investigated are published within one working day.

Summaries of aviation occurrences are published within ten working days of receipt.




Assess confidential reports for clarity, completeness and significance for transport safety and, where appropriate, advise any responsible party in a position to take action in response to the safety concerns.

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

Within six weeks advise a responsible party in a position to take safety action in response to the safety concern.




Complete and publish investigations.

Up to 60 complex investigations.

Up to 12 short investigations.

70 complex investigation reports published.

90 short investigations completed.



Complete and publish research and analysis reports, based on safety priorities and trends.

Complete and publish the annual Aviation Occurrence Statistics report and other research publications.

Reports on aviation safety trends provided to the Minister, operators and relevant sector of the industry twice per year.

Statistics report plus 3 other research reports published.

1 trend monitoring report published.


Ensure preparedness for a major accident by reviewing and testing major accident response and management capabilities through participation
in exercises.

One major exercise per annum.

Participation in three exercises.


Assist regional transport safety in the Asia Pacific region through direct cooperation with counterpart agencies and the delivery of approved support activities, provided for by program funding agreements.

Delivery of approved projects within program funding allocation.

See detailed report.


Assist the Malaysian Government with its investigation into the disappearance of Malaysia Airlines Flight MH370 in accordance with Annex 13 to the Convention on International Civil Aviation. Work with primary and secondary stakeholders in relation to decisions made by governments in relation to the search and/or potential recovery operations of MH370.

Continue to lead the search operations to search up to 120,000 square kilometres.

Continue to assist the Malaysian investigation as an Accredited Representative.

See detailed report.


Independent 'no-blame' investigations of transport accidents and other safety occurrences

This section describes the ATSB's performance against the deliverables relating to the ATSB's role as the independent 'no-blame' transport safety investigator, as published on page 126 of the 2015–16 Portfolio Budget Statements.


  • Assess, classify and publish summaries of accident and incident occurrences received. Details of occurrences being investigated are published within one working day. Summaries of aviation occurrences are ready to be published in the public online database within ten working days of receipt.
  • Assess confidential reports for clarity, completeness and significance for transport safety and, where appropriate, advise within six weeks any responsible party in a position to take safety action in response to the safety concern.
  • Complete and publish up to 60 more complex investigations and up to 120 short investigations per annum.
  • Ensure preparedness for a major accident by reviewing and testing major accident response and management capabilities through participation in one major exercise per annum.
  • The ATSB will continue to assist the Malaysian Government with its investigation into the disappearance of Malaysia Airlines Flight 370 (MH370) in accordance with Annex 13 to the Convention on International Civil Aviation. The ATSB will continue to work with primary and secondary stakeholders in relation to decisions made by governments in relation to the search and/or potential recovery operations of MH370.

Aviation investigations website Links

In 2015–16, the ATSB initiated 39 complex safety investigations—27 of which were occurrence investigations—from 16,142 accident and incident notifications (of these notifications, to date 4,998 have been classified as aviation occurrences). In addition, one other investigation started as complex, but was downgraded and continued as a short investigation.

During this reporting period, 44 complex investigations were completed (comprising 31 occurrence investigations, 12 external investigations, one research investigation and no safety issue investigations). Of the 44 complex investigations, eight were completed within 12 months.

As of 30 June 2016 there were 73 ongoing complex aviation investigations.

Marine investigations website Links

In 2015–16, the ATSB initiated seven complex marine transport safety investigations from a total of 146 accident and incident occurrences. Seven complex investigations were completed in this time period (six were occurrence investigations, one was assistance to an external organisation), one of which was completed within 12 months.

As of 30 June 2016, the marine investigation team continues to investigate seven marine occurrences (including one external investigation).

Rail investigations website Links

In 2015–16, the ATSB initiated 25 complex rail safety investigations (all occurrence investigations) from 378 notifications of immediately reportable matters.

The ATSB completed 19 complex rail investigations in 2015–16. Eleven of the 19 investigations were completed within 12 months.

As of 30 June 2016, the ATSB continues to investigate 30 complex rail safety occurrences and one safety issue investigation.

Short investigations website Links

In 2015–16, the ATSB initiated 93 short investigations—91 in aviation, one in marine and one in rail.

During this past financial year, 89 aviation short occurrence investigations were completed (28 within two months). One marine short occurrence investigation was also completed.

Research and statistics website Links

The Research Investigations team provided input into 24 aviation occurrence investigations. In addition to a single complex aviation research investigation, counted under aviation investigations above (Engine failures and malfunctions in light aeroplanes: 2009 to 2014), two educational research publications were completed in 2015–16. These were Pilot incapacitation incidents: 2010–2014 and Aerial application safety: 2014–2015 year in review.

In 2015–16, the ATSB published two aviation statistical reports, the annual Aviation Occurrence Statistics and one aviation trend monitoring review.

Details on the ATSB's research reports are provided in Section 3—Safety data recording, analysis and research.

Reporting website Links

The ATSB's target for assessing, classifying and publishing summaries of accident and incident occurrences is:

Of 146 occurrences investigated, 111 (75 per cent) were processed with summaries published on the ATSB website within one working day of the start of the investigation.

In 2015–16, 15 per cent of aviation occurrence notifications were processed and ready for publication within ten working days. The average time for processing was 150 working days.

Confidential reporting website Links

In the 2015–16 year, the ATSB's Confidential Reporting Scheme (REPCON) received 130 notifications (of which 65 were classified as REPCONs). Of these 130 notifications, 116 concerned aviation (55 REPCONs), 11 concerned rail (8 REPCONs) and three concerned marine (two of which were REPCONs).

Of the 44 REPCON reports completed in 2015–16, 23 (52 per cent) resulted in safety action by stakeholders.

The following summaries provide examples of safety concerns that were raised, along with the safety action taken after the concerns were reported through REPCON.




Technical analysis

The ATSB Technical Analysis team maintains support and readiness for the detailed examination of physical evidence and the recovery and download of recorded data from a variety of damaged and undamaged sources across the aviation, rail and marine transport modes.

The Technical Analysis team completed five complex investigations in 2015–16. Additionally, the team made significant contribution to 37 more complex investigations, across all three modes, which were published during 2015–16. A further ten investigations were completed where technical assistance in transport safety matters was formally requested from the following external agencies:

In the past year, the team expended considerable resources in continuing to provide technical input in support of the ATSB's ongoing assistance to Malaysia, in the search for MH370. The contributions were associated with the definition and refinement of the search area (via the Search Strategy Working Group) and with identification and analysis of recovered debris.

Preparedness for a major accident

Maintenance of the ATSB's operational capability and readiness extends directly to the agency's preparedness for undertaking and managing all aspects of a major transport safety investigation.

Across the 2015–16 period, the ATSB participated in several practical exercises involving hypothetical transport accidents—aimed at directly testing the effectiveness and scope of our response arrangements.

In May 2015, the ATSB attended a State Emergency Management Committee workshop in Perth, Western Australia to examine the awareness and rating of the risks associated with a major aviation accident in local or remote environs. In November 2015, at Port Melbourne, Victoria, 'Exercise BARCO' tested the TTLine (operator of the passenger ferry Spirit of Tasmania) inter-agency response arrangements to a shipboard fire. This enabled a number of ATSB's Senior Marine Transport Safety Investigators to examine our own early response procedures for such a maritime emergency.

During August 2015, a rail accident scenario was played out by local authorities near Nhill, Victoria—allowing the ATSB's Manager of Rail Safety Investigation to examine the logistics of mounting and managing an effective investigation alongside many other responding organisations.

The information gained, and observations made, from all of these activities have provided valuable input into the ATSB's continuous and ongoing improvement program for assuring our readiness to mount a full-scale investigative response in the event of a major transport accident.

Implementing the ATSB's expanded role in rail website Links

In August 2011, the Council of Australian Governments (COAG) agreed on reforms to rail safety regulation and investigation, with a view to introduce consistent national regulation and investigation capabilities. Those reforms were subsequently agreed across New South Wales, Tasmania, South Australia and the Northern Territory in 2013, Victoria in 2014, and Western Australia in 2015.

Significant progress has been achieved in developing and consolidating arrangements for effective independent rail safety investigation under the Transport Safety Investigation Act 2003. In particular, cooperation with the NSW Office of Transport Safety Investigation and Victoria's Chief Investigator of Transport Safety has been strong and productive. Through an ongoing program of ATSB-provided training and refresher programs, staff from both agencies have developed a strong working knowledge, along with practical application, of ATSB's policies, procedures and legislation.

In late 2015, the Queensland state government advised its intention to participate in the national regulatory and safety investigation reforms. Subject to the passage of revised rail safety legislation in Queensland, the ATSB will expand its role in the first half of 2017 and will then be responsible for independent rail safety investigations in all Australian states and territories.

The ATSB continues to negotiate with the states on funding for national rail investigation.

Safety data recording, analysis and research website Links

The ATSB is funded to record data and conduct analysis and research into aviation matters.

This section describes the ATSB's performance against the deliverable set out on page 126 of the 2015–16 Portfolio Budget Statements.


  • Complete and publish the annual Aviation Occurrence Statistics report and other research publications as informed by the annual research program.
  • Reports on aviation safety trends will be provided to the Minister and safety entities twice per year.

In 2015–16, the ATSB continued to analyse occurrence data held in its aviation safety occurrence database as part of Australia's international obligation to determine if preventative safety measures are required.

In addition to the above deliverables, the ATSB research and analysis section increased its role in supporting active aviation occurrence investigations during 2015–16. Significant data analysis was completed for 24 aviation occurrence investigations during the financial year. This work helped to determine the investigation scope, assist in making investigation conclusions, inform safety issue risk assessments and document past occurrences of similar incidents.

The ATSB published five research investigation reports during 2015–16.

Engine failures and malfunctions in light aeroplanes: 2009 to 2014
(AR-2013-107) website Links news Links

Through routine trend monitoring of safety occurrence reporting, the ATSB became aware of a potential issue surrounding the frequency of light aircraft engine failures and malfunctions (both Australian VH and recreationally-registered).

Over the 6 year study period, between 2009 and 2014, 322 engine failures or malfunctions involving light aircraft were reported to the ATSB and/or Recreational Aviation Australia (RAAus). These reports involved single-engine piston aeroplanes with up to 800 kg maximum take-off weight. Aircraft powered by Jabiru engines were involved in the most engine failures or malfunctions, with 130 reported over the 6 years. This represents about one in ten aircraft powered by Jabiru engines in the study set having reported an engine failure or malfunction. Reports from Rotax powered aircraft were the next most common (87, or one in 36), followed by aircraft with Lycoming (58, or one in 35) and Continental engines (28, or one in 35). When factoring in the hours flown for each of these engine manufacturers, aircraft with Jabiru engines had more than double the rate of engine failure or malfunction than any other manufacturer in the study set—3.21 failures per 10,000 hours flown.

Unlike the engines of other manufacturers in this study, nearly half of the Jabiru engine failures or malfunctions related to a fractured component. Engine through-bolt failures were the most commonly reported failure mechanism in Jabiru powered aircraft, with 21 through-bolt fractures reported between 2009 and 2014. Taking into account the number of aircraft registered in the study period, through-bolt failures occurred in about one in 55 Jabiru powered aircraft. Although originally designed to be replaced after 1,000 hours, 19 through-bolts failed before the 1,000 hour mark, with seven failing before 500 hours. At least four failures involved engines with upgraded 3/8 inch diameter through-bolt nuts. There were no failures reported involving the newer 7/16 inch diameter through-bolts, which are used in currently manufactured engines (present in about 20 per cent of Jabiru engines).

The ATSB has issued recommendations to Jabiru Aircraft Pty Ltd and the Civil Aviation Safety Authority to reduce the risk of engine failure or malfunction in aircraft fitted with Jabiru engines and to assure future reliability of these engines (see Section 6–Engine failures and malfunctions in light aeroplanes).

The ATSB research investigation report, Engine failures and malfunctions in light aeroplanes 2009–2014 (AR-2013-107), is available from the ATSB website at

Aviation Occurrence Statistics 2005 to 2014 (AR-2015-082) website Links

Thousands of safety occurrences involving Australian-registered and foreign aircraft are reported to the ATSB every year by the public and by individuals and organisations in Australia's aviation industry. The aim of the ATSB's statistical report series is to give information to pilots, operators, regulators and other aviation industry participants, about what accidents and incidents have happened, how often they are happening and what we can learn from them.

In the 10 year period of 2005 to 2014, 254 aircraft were involved in fatal accidents in Australia, leading to 374 fatalities. Most fatalities (240) were in CASA-registered (VH registrations) general aviation aircraft (including aerial agriculture, mustering, search and rescue, flying training, private and sport operations). Non-CASA registered recreational aircraft (aeroplanes, weight shift hang gliders, trikes, paragliders and powered parachutes, and gyrocopters) accounted for 98 fatalities. Commercial air transport (passenger regular public transport, charter and medical transport) accounted for 36 fatalities.

Across the 10 year period, the accident rate per hours flown was the highest for recreational aeroplanes, followed by aerial agriculture and private and sport aviation. However, the accident rate for all VH registered private and sport operations (including gliding) was similar to that of all non-VH recreational flying combined. Recreational aircraft, private/sport, and aerial agriculture operation types, were among the most likely to result in a fatal accident when considering the amount of flying activity. Within recreational aviation, half of all gyrocopters accidents were fatal and almost a third of weight shift aircraft accidents were fatal.

In 2014 alone, there was a total of 278 aircraft involved in accidents and 202 involved in serious incidents (indicating an accident nearly occurred). Twenty aircraft were involved in fatal accidents and another 28 resulted in serious injury. In 2014, Australia saw 28 fatalities and 36 serious injuries as a result of aviation accidents.

Commercial air transport recorded no fatalities in 2014. However, there were 27 accidents, an increase compared to the 10 year average of 19. Five of the accidents resulted in seven serious injuries. Most accidents (23) involved charter aircraft and were mostly collisions with terrain or failure of the landing gear. There was also a significant drop in serious incidents (37) when compared to the previous two years (mostly aircraft separation and pilot incapacitation events).

General aviation experienced 149 accidents in 2014 (the highest in 10 years), 11 of which were fatal (the lowest in 10 years) and another 15 resulted in serious injuries. These accidents led to 17 fatalities and 20 serious injuries. General aviation aircraft were involved in 118 serious incidents in 2014. In 2013—the last year with available activity data—the general aviation accident rate per departure was almost five times that of commercial air transport. The year 2013 saw a significant decrease in accident rates compared with the previous 6 years. However, the fatal accident rate was consistent with the 10 year average. Aerial agriculture, followed by private and sport aviation, had the highest general aviation accidents rates. Flying training had the lowest.

The reporting of safety incidents to the ATSB from recreational (non-VH) aviation has increased more than tenfold in the last 10 years. This is due to both the growth in recreational flying and improved awareness of reporting requirements. In 2014, 99 accidents were reported, nine of which were fatal and another eight led to serious injuries. Most accidents involved aeroplanes, as these are the most common recreational aircraft.

Aviation Occurrence Statistics 2005 to 2014 (v>AR-2015-082) is available on the ATSB website at

Pilot incapacitation occurrences 2010–2014 (AR-2015-096) news Links

Occasionally pilots become incapacitated during flight. Incapacitations can arise from different reasons. They include the development of an acute medical condition, changes in environmental conditions during the flight, or the effects of a pre-existing medical condition. The effect of incapacitation on a pilot can restrict their flight duties for the remainder of the flight, or in the case of single-pilot operations it can cause a collision with terrain.

This research report documents pilot incapacitation occurrences in high capacity air transport, low capacity air transport and general aviation, to help educate industry about the causes and risks associated with inflight pilot incapacitation.

In the past 5 years, there have been, on average, 23 pilot incapacitation occurrences reported each year. Nearly 75 per cent of the incapacitation occurrences happened in high capacity air transport operations (about one in every 34,000 flights), with the main cause being gastrointestinal illness, followed by laser strikes. In the majority of the occurrences reported, the incapacitation was severe enough for the pilot to be removed from duty for the remainder of the flight. With multi-pilot crews in high capacity operations these occurrences usually had minimal effect on the flight.

Low capacity air transport and general aviation had fewer occurrences with a wider variation of causes of incapacitation. These ranged from environmental causes (such as hypoxia), to medical conditions (such as heart attack). Furthermore, 70 per cent of pilot incapacitation occurrences in general aviation had an effect on flight operations, namely return to departure aerodrome or collision with terrain.

This report highlights that pilot incapacitation can occur in any operation type, albeit rarely. In high capacity air transport operations, the practice of ensuring all pilots on the same flight eat different meals, prior to and during the flight, has been an effective defence to prevent all pilots on the same flight becoming incapacitated at the same time. Providing pilots with training in dealing with incapacitation events has been effective for when these events do occur. Pilots are also encouraged to report laser strikes to police and the Office of Transport Security. In low capacity air transport operations, providing emergency training to non-flight crew, such as aeromedical nurses, is an important defence in case of pilot incapacitation. Finally, in general aviation, pilots are reminded to assess their fitness prior to flight. Assessment of fitness includes being aware of any illness or external pressures they may be experiencing.

Pilot incapacitation occurrences 2010–2014 (AR-2015-096) is available on the ATSB website at

Aerial application safety: 2014 to 2015 year in review (AR-2015-031) news Linkswebsite Links

This is the first publication in a series from the ATSB on aerial application (agricultural spraying and firefighting) accidents during the previous operational year (May 2014 to April 2015). Aerial application operations have a notably high accident rate relative to other aviation sectors. These operations involve inherent risks that are not present in most other types of flying. Risks include low-level flying with high workloads and numerous obstacles, in particular powerlines and uneven terrain. This report focuses on the aerial application accidents that occurred between May 2014 and April 2015, and fatal accident reports published in this period, to coincide with the agriculture season in most parts of Australia.

Aerial application safety: 2014–2015 year in review (AR-2015-031) is available on the ATSB website at

video Links

Emerging trends in Australian aviation safety January–June 2015
(AR-2016-002) website Links

When aviation safety incidents and accidents happen they are reported to the ATSB. The most serious of these are investigated, but most reports are used to help the ATSB build a picture of how prevalent certain types of occurrences are in different types of aviation operations.

The ATSB uses this data to proactively look for emerging safety trends. By monitoring trends, issues of concern can be communicated and action taken to prevent accidents.

ATSB trend monitoring reviews the rate of reported aviation occurrences biennially (per 100,000 departures or hours flown) and compares it to the 5 year average. The ATSB performs this assessment independently for every type of occurrence involving high capacity regular public transport (RPT) and charter, low capacity RPT and charter, general aviation and recreational aviation.

Further analysis can show which aircraft models, operators, or locations account for most of the difference with prevailing trends and whether this has been a long term trend or just a spike. When a single operator accounts for most of the difference, the ATSB contacts them for information and comment. Sometimes, increases in recorded occurrences are solely due to a good reporting culture, because of changes to operations, aircraft, or regulations. Sometimes there is no apparent explanation.

In 2015–16, the ATSB published one aviation safety trend report, Emerging trends in Australian aviation safety January–June 2015.

This report summarises significant trends in Australian aviation from January to June 2015, along with resultant safety action being taken to address these trends. Safety action is appropriate when a concerning trend has been identified and can include:

Emerging trends in Australian aviation safety January–June 2015 (>AR-2016-002)is available on the ATSB website at

Fostering safety awareness, knowledge and action

The ATSB is funded for activities relating to its responsibilities for increasing awareness of safety issues and complying with international safety obligations. This section describes the ATSB's performance against the deliverables set out on page 126 of the 2015–16 Portfolio Budget Statements.


  • Assist regional transport safety in the international region through direct cooperation and the delivery of approved projects and other support activities provided for by program funding agreements.

Regional cooperation news Links

During 2015–16, the ATSB continued an active program of regional engagement with other transport safety agencies, over and above that required by its international obligations. Australia's reputation for high quality and rigorous investigations makes it uniquely placed to assist with transport safety in the Asia Pacific region. In particular, the ATSB has an ongoing involvement in the Australian Government Indonesia Transport Safety Assistance Package (ITSAP) and cooperation with Papua New Guinea (PNG) consistent with the Memorandum of Understanding on Cooperation in the Transport Sector.

Many countries do not have a well-developed capability to investigate accidents and serious incidents. In this situation, the ATSB believes that the establishment of a regional accident investigation organisation, or the creation of a regional pool of qualified investigators, may be the best way to establish an effective accident and incident investigation and prevention system. Australia will pursue opportunities in this regard in the Asia Pacific region, including taking a leading role in the ICAO Asia Pacific Accident Investigation Group (APAC AIG) and the Marine Accident Investigators Forum in Asia (MAIFA).


The ATSB and the Indonesian National Transportation Safety Committee (NTSC) collaborated on a range of ITSAP activities in 2015–16, including the very successful cooperation between the ATSB and NTSC transport recorder laboratories. Activities included a 'train-the-trainer' project to develop a Fundamentals of Marine Electronic Data (FMED) course that was successfully delivered to NTSC staff and Indonesian marine industry participants in the Indonesian ports of Medan and Bali. An NTSC aviation recorder specialist visited the ATSB for on-the-job training and practical assistance related to recorder work for NTSC aviation investigations.

Papua New Guinea

Under the PNG Memorandum of Understanding on Cooperation in the Transport Sector, the ATSB has an ongoing program of cooperation and capability building with the PNG Accident Investigation Commission (AIC). An ATSB Senior Transport Safety Investigator (STSI) is deployed full-time to the AIC, in Port Moresby, to assist PNG in developing the capability to meet the international requirements for aviation safety investigation. Ongoing guidance and mentoring of PNG AIC investigators by the ATSB STSI included work in support of the AIC investigation into the crash of a Britten Norman Islander aircraft on approach to Kiunga Airport, Western Province, on 13 April 2016. All 12 people on board, including the Australian pilot, died in the accident.

Other regional engagement activities

The ATSB continues to make its expertise and resources widely available in support of regional transport safety. Representatives from Malaysia, Korea, Indonesia, Papua New Guinea, Macau and Oman visited the ATSB during 2015–16 for discussions related to transport safety. In addition, participants from New Zealand, Malaysia, Korea, Singapore, Taiwan and Macau attended ATSB investigator training courses.

Communication and education

As Australia's national transport safety investigator, we are committed to communicating the safety lessons from our investigation findings, research activity and occurrence reports. This information has valuable safety messages which can help improve transport safety and ultimately save lives.

In 2015–16 we continued to highlight, for the benefit of industry and the travelling public, emerging safety issues and trends using a range of communication channels and activities.

Stakeholder awareness

Between April and June 2016, the ATSB conducted an online survey with members of the transport industry and travelling public.

The survey sought stakeholders' opinions of the ATSB's service standards and activities. We benchmarked the findings of this survey against the results from the 2013 stakeholder survey.

More than 960 people completed the survey, which was predominately promoted via the ATSB Facebook page.

Some of the key findings of this year's survey showed that:

  • more than half of the respondents believed the ATSB's activities have increased awareness of transport safety issues in the past 2 years
  • the ATSB's strengths are our technical ability in conducting investigations and in the quality of our reports
  • the area in which the ATSB needed to improve was timeliness in completing investigations
  • there was an increase in overall knowledge of the ATSB
  • there was an increase in visits to the ATSB website.

The findings of the survey will provide valuable input into our future business planning. The ATSB greatly appreciates the time and effort of everyone who completed the survey.

SafetyWatch news Links

In 2015–16, we continued to promote our SafetyWatch initiative. SafetyWatch highlights the broad safety concerns identified from our investigations and from the occurrence data reported to us by industry.

The initiative includes priority areas where more can be done to improve safety. These include:

video Links
video Links
video Links
video Links
video Links
video Links
video Links
video Links
video Links

Throughout the year, the ATSB undertook a range of communication activities (direct mail, web news items, social media and general media) to raise awareness of these issues within the transport industry.

Social media website Links

During 2015–16, we made extensive use of our social media platforms to reach and engage with the transport industry, media and the travelling public.

In July 2015, we launched the ATSB's Facebook page to expand our online engagement with the Australian public. Since its launch, the ATSB's Facebook page has attracted around 7,500 followers and referred more than 85,000 views to the ATSB website.

The ATSB's Twitter account continues to be an effective channel for releasing reports and investigation updates. Through this social media platform, we can provide a short safety message along with a link to more information on our website.

By the end of June 2016, the ATSB's Twitter followers had increased to around 5,500 people. These include journalists, members of the public and transport industry specialists.


The ATSB undertakes responsive and proactive media activity to inform the transport industry, and travelling public, of our investigations and activities. During the year we worked closely with local, national, state and international media to raise community awareness of transport safety.

We also regularly contributed articles to key industry publications throughout the year.

Website website Links

The ATSB website ( continues to be our principal communication channel. In 2015–16, the ATSB website received 2,665,121 page views. This represents an increase of 169,320 page views from the previous financial year.

The launch of the ATSB Facebook page has been particularly effective in referring users to the ATSB website. In 2015–16, Facebook resulted in more than 85,000 sessions on the ATSB website. Facebook was the number one referral site by far.

Going digital

We are continually working to improve our website to meet audience needs and to allow for new and emerging technologies.

In 2015–16, all of our reports became available in html format (along with current pdf and rich text formats).

Having our content in html format has allowed us to embed more digital content—such as video, animation and audio. It also forms part of our response to the Australian Government's digital first agenda.

Online aviation database website Links

The ATSB National Aviation Occurrence Database contains de-identified information on aviation accidents and incidents in a searchable format. The database has been designed to fulfil searches for information involving the most common requests received by the ATSB—date range, aircraft and operation type, injury level, occurrence category and type, and location and airspace type and class. Users are able to search aviation occurrence statistics from the ATSB website.

In 2015–16, the National Aviation Occurrence Database had 6,014 page views.

Industry engagement

In 2015–16, the ATSB continued its industry engagement program. The program comprised industry events where the ATSB participated, presented and/or contributed. This represented around 35 events with stakeholders from the aviation, maritime and rail industries, including:

  • Safeskies 2015
  • Regional Aviation Association of Australia convention
  • AusRail Plus 2015
  • Airport Safety Week event
  • Advanced Marine Pilot seminars and courses
  • Australian Seafarers Welfare Council
  • Australian Federation of Air Pilots seminars
  • Airservices Australia Waypoint 2015
  • Australian Women's Pilots Association Conference
  • Aerial Application Association of Australia Convention
  • Rail Industry Safety and Standard Board Rail Safety event.

Financial performance

This section should be read in conjunction with the ATSB's audited financial statements for 2015–16 that appear in section 7 of this report.

The ATSB operates as a separate non-corporate Commonwealth entity, having been established on 1 July 2009. The main assets of the ATSB were transferred from the (then) Department of Infrastructure and Regional Development and include plant and equipment, specialised laboratory assets and intangible software assets.

The ATSB recorded a deficit of $2.5 million for 2015–16, compared to a surplus of $14.0 million in 2014–15. Excluding depreciation and amortisation, the ATSB realised an underlying deficit of $1.6 million which compares to a $14.9 million surplus in 2014–15.

ATSB's approved operating loss for 2015–16 after accounting for depreciation and amortisation was $24.3 million compared to an actual operating loss of $2.5 million mainly due to the timing differences between revenue received and originally forecast. In 2015–16 ATSB has recognised additional $27.9 million in contributions and $8.0 million in resources received free of charge from other countries in relation to the search for the missing Malaysia Airlines flight 370 (MH-370), with the majority of the additional contributions expected to be fully utilised in 2016–17.

Non-financial assets are mainly comprised of Information and Communication Technology hardware and software applications and Laboratory equipment required to deliver ATSB's core activities and leasehold improvements on rental accommodation.

The Government no longer provides appropriation funding to cover non-cash expenses of depreciation and amortisation to non-corporate Commonwealth entities. In the absence of revenue for depreciation and amortisation, the ATSB and other non-corporate entities are more likely to deliver a negative operating result or deficit, and these will accumulate. Offsetting this build-up of retained deficits requires a commitment by the Government to provide annual capital injections to meet new capital requirements.

The ATSB's new capital requirements are detailed in its Departmental Capital Budget published in the 2015–16 Portfolio Budget Statements. Over time, the ATSB's estimated capital injections fall short of the deficits associated with the non-funding of depreciation and amortisation. Without adequate capital injections by Government, this presents a challenge to the ATSB in maintaining its underlying equity and asset capability going forward.

Table 4: Summary of financial performance and position





Revenue from Government



Other revenue



Total income



Employee expenses



Supplier expenses



Depreciation and amortisation



Total expenses



Operating surplus/(deficit)



Financial assets




Non-financial assets








Net Assets - A + B – C



The search for Malaysia Airlines Flight MH370 website Links


On 8 March 2014, Malaysia Airlines Flight 370 (MH370), a Boeing 777-200ER registered 9M-MRO, was travelling on a scheduled international passenger flight from Kuala Lumpur to Beijing. There were 239 people on board—12 Malaysian crew members and 227 passengers. Six of the passengers were Australian citizens.

During the transition from Malaysian airspace to Vietnamese airspace, the aircraft, for unknown reasons, lost contact with air traffic control. It also disappeared from air traffic control secondary surveillance radar.

It was later determined (through review of primary radar data) that, after disappearing from secondary radar, the aircraft had turned and flown back over the Malaysian peninsular prior to a further turn in a north westerly direction to fly through the Malacca Strait. The aircraft was last detected on primary radar above the northern tip of Sumatra.

After the final detection of the aircraft on primary radar, the only available information relating to the aircraft's flight path was derived from information recorded during a series of satellite communications between the ground station and the aircraft's satellite communication system, via Inmarsat's Indian Ocean Region satellite. Analysis of this satellite data indicated that MH370 continued to fly for around six hours after radar contact was lost.

The data associated with the periodic satellite transmissions during the flight and the aircraft's performance have been extensively analysed. This analysis indicates that the aircraft entered the sea close to a long, but narrow, arc in the southern Indian Ocean.

Early searches

Under agreement between Australia and Malaysia, a surface search of probable impact areas along the arc was carried out from 18 March to 28 April 2014, coordinated by the Australian Maritime Safety Authority. This included a search for the flight recorders using a towed pinger locator, sonar buoys and an autonomous underwater vehicle (AUV) to search the ocean floor, in the northern section of the search area. The AUV underwater search, coordinated by the Joint Agency Coordination Centre (JACC), was completed on 28 May 2014. The ATSB then became responsible for refining the search area and leading an expanded underwater search.

Defining the underwater search area

Since May 2014, the Search Strategy Working Group (SSWG), coordinated by the ATSB, has been working towards defining the most probable position of the aircraft at the time of the last satellite communication. The SSWG brings together satellite and aircraft specialists from the following organisations:

  • Air Accidents Investigation Branch (UK)
  • Boeing (USA)
  • Defence Science and Technology Group (Australia)
  • Department of Civil Aviation (Malaysia)
  • Inmarsat (UK)
  • National Transportation Safety Board (USA)
  • Thales (UK).

These agencies work, both independently and collaboratively, as the Flight Path Reconstruction Group. Using various techniques, the group has undertaken analysis of the satellite communication information to produce probable flight paths. The SSWG also continues to consult with the SATCOM sub-group, which is part of the wider Malaysian investigation group.

Following the surface search, the Flight Path Reconstruction Group continued to analyse both the flight and satellite data, and reached a consensus on the initial priority underwater search area. In June 2014, the ATSB published a report, MH370—Definition of Underwater Search Areas, describing the methods and means used to identify a priority search area of 60,000 square kilometres. Work continued on refinements to the analysis of the satellite communications data, with the understanding that the ongoing work could result in changes to the prioritisation and locale of search activity. In August 2014, the ATSB published an updated version of the report, which included additional explanatory material relating to the Perth ground station.

In October 2014, the ATSB published MH370—Flight Path Analysis Update, which described the continuing work to define the underwater search area. Among other insights, further analysis gave greater certainty about when the aircraft turned south into the Indian Ocean and produced a better understanding of the parameters within which the satellite ground station was operating during the last flight of MH370. The analysis indicated that the underwater search should be prioritised further south within the wider search area.

Refinements to update the search area definition continued during 2015–16, with the Australian Defence Science and Technology Group (DST Group) conducting a comprehensive analysis of available data. In December 2015, the ATSB published an updated report, MH370 – Definition of Underwater Search Area, which describes the results of the DST Group analysis.

The analysis, based on Bayesian techniques, models the satellite communications (SATCOM) data, the aircraft dynamics and the environmental conditions during the flight. The SATCOM model was calibrated using data from B777 flights, including previous flights of the accident aircraft. Validation experiments were also conducted, to ensure that the modelling could predict the actual flight path of previous flights of the accident aircraft using available flight data.

The output of the DST Group analysis was a probability density function (PDF) defining the probable location of the aircraft's crossing of the 6th arc. These results were then extrapolated to the 7th arc. The analysis indicated that the majority of solutions (flight paths predicted by the model) only contained one significant turn after the last recorded radar data. DST Group have written a book, Bayesian methods in the search for MH370, detailing the entire analysis.

Performance analysis by Boeing produced a series of achievable ranges, with time intervals, for different cruise altitudes. It was noted that maintaining a constant altitude of FL350, or higher, gave range values that closely matched the region on the arc corresponding to the DST Group analysis results. The DST Group and Boeing results were obtained independently and it is significant that they were in general agreement.

In addition to the series of data points that were recorded from the SATCOM system, only the following indirect information was available to assist the ATSB in determining the end-of-flight scenario and therefore the search area width:

  • probable aircraft systems status
  • simulator results
  • review of previous accidents
  • glide distance.

The original ATSB underwater search area definition report, published in August 2014, identified a width of 20 NM behind the arc and 30 NM forward of the arc as the priority search area width. This primary priority width was later widened to account for simulated aircraft behaviour following fuel exhaustion. Work has continued refining the analysis of the satellite communications, and other data, to assist in defining the search area width.


In April 2015, senior Ministers from Malaysia, Australia and the People's Republic of China (referred to as the Tripartite) met to discuss the next steps in the search for MH370. The Ministers agreed that if MH370 was not found within the 60,000 square kilometre search area, the search area would be extended by an additional 60,000 square kilometres (bringing the total search area to 120,000 square kilometres) to cover the entire highest probability area identified by expert analysis.

The resourcing commitments from the Tripartite for the underwater search for MH370 totals A$180 million, to search an area of 120,000 square kilometres. The outline of the resourcing commitments follow.

Australian Government contribution

As announced in the Federal Budget on 13 May 2014, the Australian Government has committed up to A$89.9 million over 2 years from 2013–14, as part of Australia's contribution to the search for MH370. This Australian Government funding included up to A$60 million for the ATSB to undertake the underwater search.

Malaysian Government contribution

On 28 August 2014, Australia and Malaysia signed a Memorandum of Understanding on areas of cooperation in search activities, including financial arrangements. The Malaysian Government's contribution to the underwater search for MH370 totals A$100 million, as follows:

  1. an initial contribution of up to A$60 million, to match the contribution by Australia
  2. an additional contribution of A$20 million, as agreed at the April 2015 Ministerial Tripartite meeting
  3. a further contribution of A$20 million, in December 2015.

In addition, Malaysia provided a number of vessels and equipment that have been utilised in the search.

People's Republic of China (China) Contribution

In December 2015, China confirmed it would contribute A$20 million to the underwater search that included the provision of the vessel Dong Hai Jiu 101. A formal agreement between the ATSB and the Dong Hai Rescue Bureau was signed on 15 March 2016.


The sea floor in the search area has been progressively mapped to help ensure the safe operation of the sonar search systems. Fugro Equator uses a hull mounted multibeam sonar system to gather bathymetric and other data relating to the seafloor. Processing of this data by staff at Geoscience Australia has revealed many new seabed features, providing necessary information to plan the operation of sonar-equipped vehicles close to the sea floor. By mid-June 2016, around 271,000 square kilometres of search-related area had been surveyed since May 2014. Additional bathymetry data is gathered during transit to and from port visits.

Underwater search

2015–16 is the second full year of the underwater search for MH370. At 30 June 2016, a total of around 110,000 square kilometres had been searched, with more than 55,000 square kilometres being searched in 2015–16.

Fugro Discovery continued underwater search operations during the year with a 6,000 m rated Edgetech DT deep tow system (towfish), tow winch and mission crew.

Figure 1: Fugro Discovery

Fugro Discovery

Source: Oliver Edwards

In addition to performing bathymetric survey work, Fugro Equator also continued underwater search operations using similar equipment to Fugro Discovery. The towfish on each of the Fugro vessels are towed on a cable at slow speed up to 10 km behind the vessel, at an altitude of between 100 m and 150 m above the sea floor. The towfish is fitted with a side-scan sonar, which surveys a wide swathe of the sea floor either side of the towfish, and a multibeam echo sounder, which surveys the sea floor immediately under the towfish.

Figure 2: Fugro Equator

Fugro Equator

Source: ATSB

In December 2015, the Fugro vessel Havila Harmony joined the underwater search, with the Hugin 4500 AUV fitted with sonar equipment similar to that used by the DT towfish.

An AUV is a free swimming (it is not connected to the vessel by a cable) submersible vehicle with a battery-powered propulsion system. The vehicle is highly manoeuvrable and therefore capable of surveying difficult terrain in some parts of the search area more effectively.
The AUV, using a purpose-built launch and recovery system, dives to the seafloor where it executes a pre-programmed mission. When the mission is complete, the AUV ascends and is recovered by the vessel in order for the acquired data to be downloaded and the AUV's batteries to be changed out with a spare charged set.

The AUV was used to search gaps in deep tow sonar coverage, due to difficult seafloor terrain. Havila Harmony and the AUV left the underwater search at the end of March 2016. The AUV remains stored in Fugro's warehouse in Perth where it can rejoin the underwater search at short notice.

Figure 3: Havila Harmony

Havila Harmony

Source: ATSB

In February 2016, the Chinese vessel Dong Hai Jiu 101 joined the underwater search after extensive preparatory engineering work in Shanghai and the mobilisation of the ProSAS 60 synthetic aperture sonar search system.

The search equipment and mission crew are provided by Phoenix International (Phoenix) and their sub-contractors.

While similar in operation to the Edgetech DT towfish, the ProSAS 60 towfish gathers and processes data differently, resulting in higher resolution imagery of the seafloor than is possible using conventional side scan sonar of a similar frequency and range.

Figure 4: Dong Hai Jiu 101

Dong Hai Jiu 101

Source: ATSB

Search challenges

This year, underwater search operations in the southern Indian Ocean have encountered a number of significant challenges including 'lost' and subsequently recovered equipment, medical evacuation of unwell crew and severe weather.

Lost towfish

Loss of Fugro 'Intrepid' towfish

On the morning of 24 January 2016, Fugro Discovery was undertaking deep tow search operations in the search area. The towfish, Intrepid, was approaching an underwater feature (volcano) which rose from a seafloor depth of 3,700 m to a depth of 2,100 m, with a gradient of 20° to 30°. Intrepid collided with the side of the volcano, at a depth of 2,550 m, and separated from the tow cable.

Intrepid was successfully recovered on 3 February 2016, using a Remotely Operated Vehicle (ROV) which had been mobilised on Havila Harmony.

Loss of Phoenix ProSAS 60 towfish

On 21 March 2016, the tow cable became slack and communication was lost with the ProSAS 60 towfish. The depressor and towfish had separated from the tow cable in 3,600 metres of water.

Phoenix subsequently mobilised their 6000 m rated Remora III ROV on Dong Hai Jiu 101 and on 18 April 2016 both the towfish and the depressor were recovered.

Medical evacuations

Three medical evacuations took place during 2015–16 for sick or injured crew—two on board Fugro Discovery and one from Dong Hai Jiu 101. Decisions in relation to medical evacuations are made by the doctor on board the vessel, in consultation with onshore medical advice. The crew member's welfare is always the primary consideration. Medical evacuations are undertaken when medical treatment for an illness or injury in a shore-based hospital is in the patient's best interest.


Weather severely impacted search operations during the latter stages of 2015–16. The vessels have experienced extreme weather conditions since May 2016 and sea states which at times prevented the safe launch or recovery of search systems.

Contacts of interest

As the search progresses, sonar analysts on board the vessels and ashore, identify and assess sonar 'contacts'—features or objects on the seabed that stand out from their surrounds which may require further investigation. Contacts of interest include anything that appears to be man-made or potentially exhibits characteristics of an aircraft debris field.

While various objects have been, and will continue to be, detected on the sea floor, most are related to geomorphology and none have yet fit the profile of an aircraft debris field. When a possible debris field is detected using the wide area coverage lower frequency sonar, the search operation will investigate it further using higher frequency sonar and optical imaging.

Classification 3 is assigned to sonar contacts that are of some interest as they stand out from their surroundings but have low probability of being significant to the search. The underwater search, so far, has identified more than 500 seabed features that have been categorised as classification 3.

Classification 2 sonar contacts are of more interest but are still unlikely to be significant to the search. There have been more than 40 features that have been categorised as classification 2. These objects may or may not be man-made, but expert analysis of the sonar imagery ranks them as having a low probability of being an aircraft debris field. Many of these sonar contacts have been reacquired and eliminated using the Fugro AUV or deep tow systems.

On 19 December 2015, an anomalous sonar contact was identified in the course of the underwater search as a Classification 2 contact, with analysis suggesting the object was likely to be man-made, probably a shipwreck. Havila Harmony was tasked with further examination of the contact using the AUV. On 2 January 2016, the AUV captured high-resolution sonar imagery of the contact, confirming that it was indeed the wreck of a ship.

The Shipwreck Galleries of the Western Australian Museum conducted a preliminary review of the sonar imagery and advised that the vessel is likely to be a steel/iron vessel dating from the turn of the 19th Century.

Figure 5: A shipwreck discovered in December 2015

Shipwreck discovered in December 2015

Source: ATSB

Classification 1 sonar contacts are of high interest and warrant immediate further investigation. When a Classification 1 sonar contact is reported, the search vessels are instructed to gather higher resolution/high frequency sonar data flying the AUV or towfish closer to the seafloor—at an altitude of between 35 and 50 m. If the high-resolution sonar data looks promising, a photo mission is run at very low altitude—between eight and ten metres—to positively identify any objects on the seafloor. Generally, these contacts are rare, with only two marked to date. They were found to be a rock field and an old wooden shipwreck.

Discovery of aircraft debris

During the year, a number of items of aircraft debris were discovered on the shorelines of western Indian Ocean nations. Five pieces were recovered and examined—one by the French authorities and four by the ATSB. The other parts are being retrieved by the Malaysian Investigation Team for further assessment.

On 29 July 2015, a part resembling an aircraft flight control surface was found on La Réunion Island in the western Indian Ocean. The part was recovered by the French judicial authorities and examinations subsequently confirmed that it was a right flaperon (an aircraft flight control surface) from MH370. Since then, other items have been recovered in Mozambique, South Africa and Mauritius and are now considered almost certainly to be from MH370. More recently, a section of wing flap was discovered in Tanzania and is being examined by the ATSB.

Figure 6: Investigators examine a piece of aircraft debris


Source: ATSB

Apart from the flaperon, which has been retained by the French authorities, the other four parts were transported by safehand to Australia for examination.

The recovery and locations of MH370 parts are important to the aircraft search as they may provide information on the paths the parts have taken through the Indian Ocean, possibly giving information on where they originated (splash point).

Examination methods used to inform the search include:

  • part identification
  • marine ecology examination
  • drift analysis of the parts
  • failure analysis.

Part identification

It is important to initially determine whether the recovered parts are, in fact, from a Boeing 777 (B777) aircraft and the likelihood that they originated from MH370. Examinations were conducted of identifying features, part numbers, serial numbers, paint and decal details and conformity to Boeing manufacturing drawings. The results of the four parts examined by the ATSB indicate that they almost certainly came from MH370. More information on the examinations is available in the debris examination updates (AE-2014-054) on the ATSB website at

Marine ecology examinations

As the parts arrived in Australia for examination, they were first taken to the quarantine facilities at Geoscience Australia for the marine ecology to be removed and examined. All parts showed evidence of colonisation by marine ecology, however most had already been removed, likely through scavenger activity soon after beaching. The internal cabin part from Rodrigues Island contained a substantial amount of remnant ecology and barnacle attachments, with the largest individual barnacle specimen being over 20 mm in length.

The on-going marine ecology identification and examinations are being conducted by the Australian National University (ANU) in collaboration with other institutions3 and are important to help understand where the parts travelled in the ocean. As barnacles and other organisms develop and grow, they retain indicators of the temperature and salinity of the seawater conditions in which they were growing. This information can be used, in comparison with known oceanographic data, to determine the ocean areas where the barnacles developed. While not a precise indicator, this method can give an approximate path of the floating parts through the ocean. Collaboration between French and Australian institutions is taking place on the barnacle specimens from the flaperon which is held by the French.

Drift analysis

Another method to determine the origin of recovered aircraft parts is the drift analysis of the parts through the ocean. This work is being conducted by specialists at the Commonwealth Scientific and Industrial Research Organisation (CSIRO) and utilises the work of the Global Drifter Program, which has been monitoring drifting buoys deployed in the Indian Ocean over the last 30 years, as well as global ocean modelling based on satellite measurements. Results to date indicate that the drift patterns of the recovered parts are not inconsistent with the current search area for the aircraft. Details of the drift analysis work is available on the CSIRO website at

The CSIRO is undertaking further drift analysis using physical replicas of the flaperon built by ATSB. This will help measure the difference between their windage factors (drift speed and direction in relation to wind velocity) and that of Global Drifter Program drifters. The results of this work will enhance the accuracy and reliability of the drift analysis, in order to refine the understanding of the likely behaviour and paths of drifting aircraft parts.

Failure analysis

Where considered of value, the recovered aircraft parts were subjected to failure analysis to determine how they failed and separated from the aircraft. The results of this work may provide indications, such as flight control positions—whether the aircraft flaps were extended or retracted at the time of failure—which may inform the end-of-flight scenarios being considered. This work is ongoing.


In the event that the aircraft is found and is accessible, Ministers from Malaysia, Australia and the People's Republic of China have agreed to plans for recovery activities—including securing all necessary evidence for the investigation, in accordance with the requirements of Annex 13 to the Chicago Convention.

Further to the agreement by the Tripartite that Australia, through the ATSB, would be the coordinating authority for the intensified underwater search, the Tripartite also agreed that Australia, through the ATSB, would lead the recovery operations should the aircraft be positively identified. Preparations have been made so that a recovery operation can be mobilised efficiently and effectively when needed.

1 Includes occurrence, safety issue, external and research investigations conducted under the TSI Act.

2 A further 27% of non-critical safety issues were still pending safety action at the time of publication.

3Including the Australian Museum, the Western Australian Museum, the Museum and Art Gallery of the Northern Territory and the Museum of Tropical Queensland.