Management and accountability

The Commission news Links

The ATSB is governed by a Commission, comprising a Chief Commissioner and three part-time Commissioners.

The Commission provides guidance on the selection of accidents and other safety incidents to be investigated. It also supports the ATSB in encouraging safety action ahead of final reports, thus reducing the need to issue safety recommendations.

The Commission operates within the corporate governance framework of the ATSB Commission Governance Manual, which is updated at Commission meetings when required. The manual sets out the Commission's legislative requirements, parliamentary and ministerial accountability, membership and functions, administrative policies and procedures and reporting obligations.

The Commission meets at least quarterly, and regularly deals with business electronically in accordance with its obligations under the TSI Act and its agreed policies.

All Commissioners participated in four meetings during 2015–16. The Commissioners also attended an annual planning session with senior management in March 2016.

Executive management

The ATSB Executive meets weekly to discuss strategic management issues and priorities. The ATSB Executive consists of the Chief Commissioner, the General Managers of Aviation Safety Investigations, Surface Safety Investigations and Strategic Capability, and the Program Director, Operational Search for MH370.

Audit Committee

The Audit Committee provides independent assurance and advice to the Chief Commissioner on the ATSB's risk management, internal controls, financial statements and legislative compliance. The Audit Committee is made up of an independent chair, an independent member and an ATSB management nominee. The Committee's quarterly meetings were held in October 2015 and February, April and June 2016.

The core work of the Committee during the year was to oversee and advise on:

The Committee is also taking a key role in advising on the governance and financial management of the search for MH370.

The audit program for 2015–16 focused on assuring the ATSB's legislative compliance and performance against its core functions. The program included the following internal audits:

Professional Committee

The Professional Committee provides for open communication on matters that affect the professional interests of ATSB staff in the workplace. The role of the Professional Committee is to:

The Professional Committee comprises 12 elected staff members, who met on three occasions during 2015–16.

Business planning and reporting

Each year, the ATSB develops an Annual Plan—consistent with the strategic direction provided through its Corporate Plan, which is published on the ATSB website. The Annual Plan incorporates the operational priorities, activities, deliverables and key performance indicators for the financial year.

The ATSB Annual Plan 2015–16 gave priority to:

Performance reporting for the Annual Plan is contained in Section 3 of this annual report.

Risk management

Consistent with the PGPA Act, the ATSB's Risk Management Framework is an integral element of its governance, planning and management framework. Risk assessment and mitigation have been integrated into ATSB business practices, planning and performance reporting—at both corporate and business unit levels.

The ATSB is committed to a comprehensive, coordinated and systematic approach to the management of risk—directed towards supporting managers at all levels to anticipate and plan for risk, and to respond appropriately. For 2015–16, the ATSB concentrated its risk focus on the areas of service delivery, health and safety, security, financial/economic, compliance and reputation.

The ATSB Enterprise Risk Register and Management Plan and Risk Policy are reviewed regularly by the Commission, the Executive and the Audit Committee. Ongoing review of risk management planning ensures the ATSB is well-placed to achieve the objectives of its risk management policy and that risk management is consistently practiced across the agency.

Business Continuity Plan

The ATSB's Business Continuity Plan provides a framework to ensure the ATSB is well-placed to manage a business disruption, implement recovery processes and build business resilience.

In 2015–16, the ATSB continued to review and test its operational risk management processes and responses, which mitigate the impact of non-routine business disruptions. A testing exercise conducted in October 2015 demonstrated the management team's in-depth knowledge of the ATSB's service obligations, business operations and resource requirements in the event of a business disruption.

The Audit Committee regularly reviews the ATSB's business continuity operations.

Fraud control

In accordance with the PGPA Act, the ATSB has in place the ATSB Fraud Control Plan 2016–18.

The ATSB's fraud risk register is reviewed on a quarterly basis and continually monitored to minimise the incidence of fraud. This process is assisted through the development, implementation and regular assessment of its fraud prevention, detection, and response strategies.

The introduction of the Public Interest Disclosure Act 2013 in January 2014, and the development of the ATSB policy and procedure for making a disclosure under the scheme, has complemented the ATSB's fraud management strategies. The ATSB's staff awareness program incorporates activities for existing and new staff.

The Audit Committee and Commission receive regular reports on fraud risks and the implementation of controls and treatments. The Committee, and the Commission, review the Fraud Control Plan to ensure the ATSB has appropriate processes and systems in place to capture, and effectively investigate, fraud-related information.

There were no allegations, or instances, of fraud reported within the ATSB during 2015–16.

Ethical standards news Links

During the reporting period, the ATSB continued to demonstrate its commitment to the APS Values, Employment Principles and Code of Conduct by:

Management of human resources

Over the past year, the ATSB's Organisational Development team has continued to focus on a range of workforce planning activities designed to position the agency to operate within a resource-constrained environment.

These activities included:

Given the finite nature of ATSB human resources, representing an associated employee cost of approximately 65 per cent of the agency's current and projected budgets, it is imperative that strategies are developed and implemented to maximise the utilisation of these resources. Accordingly, the revised strategic workforce plan has been designed to cover a broad range of strategies including:

Each of these strategies has been underpinned by a number of key activities that will be routinely reviewed through the Executive and Commission, and quality assured through the Audit Committee.

Over this reporting period, there has been a particular focus on addressing workforce risks and analysing the agency's ongoing capacity to maintain its primary objective, key functions and broader portfolio responsibilities. This is within the context of the ATSB having been subjected to successive reductions to its base appropriations, with further reductions projected over its forward estimates. This has resulted in a progressive reduction in the ATSB's core capabilities (staffing profile including specialist investigators) by about 25 per cent since it was established as an independent statutory authority in July 2009.

If the ATSB is unable to arrest this situation through increasing its core appropriations over the out-years, it will need to carefully consider which of its key functions and deliverables can be supported by a diminishing workforce. These challenges and associated risks have been identified through the ATSB's Corporate Plan.

Compounding this scenario, the ATSB also anticipates that a significant number of experienced investigators are likely to transition to retirement over the short-to-medium term. While the ATSB will implement a range of workforce planning strategies to mitigate the resulting loss of organisational knowledge and experience, people with skills and capabilities to replace these staff are in high demand and can often command a market premium beyond that which the ATSB is capable of remunerating.

Staffing profile

In accordance with our workforce planning projections, the ATSB's staffing profile has continued to decrease from 110 at the start of July 2015 to 103 at the end of June 2016. The associated staff turnover rate was approximately 13 per cent. Table 17 displays the ATSB staff numbers, by classification, as of 30 June 2016.

Table 17: ATSB staffing profile at 30 June 2016








Statutory Office Holders





Senior Executive Service Band 1



EL 2







EL 1




























This total is comprised of the following employment arrangements:

There are no other employment arrangements in place and there is no provision for performance pay.

This total comprises 86 staff based in Canberra, nine based in Brisbane, four based in Adelaide, three based in Perth and one in Sydney.

Indigenous employees

At 30 June 2015 and 30 June 2016, the ATSB had no ongoing or non-ongoing employees who identify as Indigenous.

Salary rates

Table 18 displays the salary rates supporting the above employment arrangements at 30 June 2016.

Table 18: ATSB salary rates at 30 June 2016




Statutory Office Holders

As determined by the Remuneration Tribunal




EL 2



EL 1












* Maximums include Transport Safety Investigator and respective supervisor's salaries, representing
a $1,924–$9,842 increase on standard APS6–EL2 rates.

Organisational culture news Links

This has been another unsettling year for our employees—taking into account our resource constrained environment, a number of workforce restructures and a protracted bargaining process. Fortunately, though, it appears our enduring organisational culture, and underlying morale, have been able to weather another difficult period. As demonstrated by our agency's wellbeing indicators, derived from the 2016 staff census results, it is pleasing to see that our staff remain positive in terms of job roles, attachment to the agency, feelings of personal accomplishment, attitude towards managers, workplace safety and work-life balance—as evidenced by these census results:

Conversely there are a number of results (trends) that have been identified as new and ongoing challenges, which have been captured within the revised strategic workforce plan and supporting implementation plan. They are as follows:

Training and development news Links

The ATSB, as a former Registered Training Organisation, awarded 15 Transport Safety Investigation Diplomas in 2015–16. At the same time the ATSB has continued to provide training opportunities for a broad range of industry-based personnel, through its highly regarded Human Factors, On-site safety and Aircraft Accident Investigation Fundamentals courses.

Unfortunately, as a consequence of further reductions in its staffing profile, the ATSB determined that it no longer had the necessary resources to maintain its status as a Registered Training Organisation. Accordingly, the ATSB relinquished this status on 18 March 2016. This was a particularly difficult decision given the ATSB had held this status for 13 consecutive years. It remains unclear as to how the ATSB will be able to gain formal qualifications for its investigation staff into the future. Ideally, pending increased funding, the ATSB would re-establish its status to deliver this highly sought-after and well-regarded qualification.

In terms of other professional development and industry awareness-type programs, the ATSB has been required to limit these opportunities due to its ongoing financial constraints. That acknowledged, approximately 10 per cent of staff were engaged in a range of tertiary studies, including:


The ATSB purchases goods and services in accordance with the Commonwealth Procurement Rules (CPRs). These rules are applied through the Accountable Authority Instructions. The ATSB's procurement policies and processes have been developed to ensure that:


The ATSB engages consultants when it lacks specialist expertise, or when independent research, review or assessment is required. Consultants are typically engaged to:

Before engaging consultants, the ATSB takes into account the skills and resources required for the task, the skills available internally and the cost effectiveness of engaging an external contractor. The decision to engage external contractors is made in accordance with the CPRs and relevant internal policies.

During 2015–16, one new consultancy contract was entered into involving total actual expenditure of $32,000. There were no ongoing consultancy contracts carried over from the 2014–15 year.

Annual reports contain information about actual expenditure on contracts for consultancies. Information on the value of contracts and consultancies is available from the AusTender website at

Australian National Audit Office access clauses

There were no contracts that did not provide for the Auditor-General to have access to the contractors' premises during 2015–16.

Exempt contracts

No contracts were exempted, on public interest grounds, from publication with AusTender during 2015–16.

Procurement initiatives to support small business

The ATSB supports small business participation in the Commonwealth Government procurement market. Small and Medium Enterprises (SME) and Small Enterprise participation statistics are available on the Department of Finance's website at

The ATSB seeks to support SMEs, consistent with paragraph 5.4 of the Commonwealth Procurement Rules. It ensures that its communications are expressed in clear and simple language. Its finance system is set up to ensure prompt payments to all contractors and suppliers and it makes use of credit cards.

Paragraph 11.1(a) of the Legal Services Directions 2005, issued by the Attorney General under the Judiciary Act 1903, requires chief executives of departments and agencies to ensure that legal services expenditure is appropriately recorded and monitored. Chief executives must also ensure that their agencies make records of their legal services expenditure for the previous financial year available by 30 October in the following financial year. The following amounts are exclusive of GST.

The expenditure on legal services for 2015–16 was $285,777.48, comprising:

External scrutiny and participation

Coronial inquests

The ATSB was not required to participate in any coronial inquests in 2015–16.

Other assistance to coroners

ATSB investigation: Collision with terrain—Piper PA-31P-350, VH-PGW, 6 km NW of Bankstown Airport, NSW, 15 June 2010 (AO-2010-043)

On 14 August 2015, Deputy State Coroner, Paul MacMahon, made findings following an inquest for a collision with terrain involving Piper PA-31P-350, VH-PGW, 6 km NW of Bankstown Airport, NSW on 15 June 2010. Both occupants of the aircraft were fatally injured. The ATSB was not required to attend the inquest.

The ATSB's investigation found that following the shut-down of the right engine, the aircraft's airspeed and rate of descent were not optimised for one engine inoperative flight. In addition, spectral analysis indicated it was unlikely that the left engine was being operated at maximum continuous power as the aircraft descended. As a result, the aircraft descended to a low altitude over a suburban area and the pilot was then unable to maintain level flight, which led to the collision with terrain.

Examination of the engines, propellers and governors and other aircraft components found no evidence of any pre-impact faults. However, the engine surging identified by the spectral analysis of radio transmissions during the flight was consistent with uneven fuel distribution to the cylinders.

The ATSB released its findings on 20 December 2012. The Coroner determined that the cause of death was from the effects of fire and inhalation of the products of combustion, which the pilot sustained when the aircraft suffered engine failure and, as a result, impacted with the ground and became engulfed in flames.

The ATSB's investigation report (AO-2010-043) is available on the ATSB website at

ATSB investigation: Helicopter winching accident involving Bell Helicopter Co. 412EP, VH-VAS, 19 km south-south-east of Mansfield, Victoria, 31 August 2013 (AO-2013-136)

On 4 September 2015, Victorian Coroner, Stella Stuthridge, made findings without an inquest for a helicopter winching accident involving Bell Helicopter Co. 412EP, VH-VAS, 19 km south-south-east of Mansfield, Victoria on 31 August 2013. The patient slipped out of the rescue strop and fell to the ground, sustaining fatal injuries.

The ATSB found that, due to the compressive nature of the rescue strop around the patient's chest, combined with the patient's weight and pre-existing medical conditions, the patient probably lost consciousness during the winch operation. While the rescue strop was serviceable at the time, it was not suitable for the patient and contributed to the fall from the strop following loss of consciousness.

The ATSB released its findings on 31 August 2013. The Coroner agreed with the ATSB's findings.

The ATSB's investigation report (AO-2013-136) is available on the ATSB website at

ATSB investigation: Loss of control and collision with terrain involving Cessna 182 VH-AUT, Hamilton Airport,
Victoria, 23 September 2013 (AO-2013-163) news Links

On 17 November 2015, Victorian Coroner, Peter Mellas, made findings without an inquest for a loss of control and collision with terrain occurrence involving Cessna 182 VH-AUT at Hamilton Airport, Victoria on 23 September 2013. The pilot was fatally injured.

The ATSB found that following an aborted landing during circuit training in dark night conditions, the solo student pilot lost control of the aircraft, resulting in a collision with terrain. There was insufficient evidence to determine the reason for the loss of control.

The ATSB released its findings on 23 September 2013. The Coroner agreed with the ATSB's findings.

The ATSB's investigation report (AO-2013-163) is available on the ATSB website at

ATSB investigation: Collision with terrain involving Cessna 182, VH-KKM, 19 km WSW of Mount Hotham Airport,
Victoria, 23 October 2013 (AO-2013-186) news Links

On 14 September 2015, Victorian Coroner, Ian Watkins, made findings without an inquest for a collision with terrain involving Cessna 182, VH-KKM, 19 km WSW of Mount Hotham Airport, Victoria on 23 October 2013. The pilot sustained fatal injuries.

The ATSB found that the Visual Flight Rules qualified pilot had minimal recent flying experience and had departed Moruya with less-than-visual meteorological conditions forecast along the planned route. It was very likely that these conditions were encountered shortly after passing Mount Hotham Airport, while flying over the Alpine National Park. From the evidence available it was likely that the pilot encountered reduced visibility to the extent that terrain avoidance could not be assured, resulting in the aircraft colliding with terrain in controlled flight.

The ATSB released its findings on 23 October 2013. The Coroner agreed with the ATSB's findings.

The ATSB's investigation report (AO-2013-186) is available on the ATSB website at

ATSB investigation: Collision with terrain involving a Lancair Legacy, VH-ICZ, Shepparton Airport Victoria on
25 October 2013 (AO-2013-193) news Links

On 23 October 2015, Victorian Coroner, Ian Watkins, made findings without inquest for a collision with terrain involving a Lancair Legacy, VH-ICZ at Shepparton Airport, Victoria on 25 October 2013. The pilot and passenger on board were fatally injured.

The ATSB found that shortly after take-off, and for reasons which could not be determined, the aircraft entered a steep climb. It then, likely, entered an aerodynamic stall and began a descending right turn that continued until the aircraft collided with terrain.

The ATSB released its findings on 25 October 2015. The Coroner agreed with the ATSB's findings.

The ATSB's investigation report (AO-2013-193) is available on the ATSB website at

Civil proceedings

The ATSB initiated proceedings in the Federal Court against a rail operator who claimed Legal Professional Privilege in response to the ATSB's use of coercive information gathering powers for an investigation. The matter was settled prior to the hearing with the rail operator providing the documents sought.