Contents

  • Letter of transmittal
  • Introduction
  • Section 1
  • Chief Commissioner’s review
  • Chief Commissioner’s review 2016–17
  • Section 2
  • Agency overview
  • Agency overview
  • ATSB organisational structure
  • Commission and Executive Management team
  • Outcome and program structure
  • How the ATSB reports
  • Section 3
  • Report on performance
  • Report on performance
  • Independent ‘no-blame’ investigations of transport accidents and other safety occurrences
  • Safety data recording, analysis and research
  • Fostering safety awareness, knowledge and action
  • Financial performance
  • The search for Malaysia Airlines Flight 370
  • Section 4
  • Significant safety investigations
  • Aviation investigations
  • Rail investigations
  • Marine investigations
  • Section 5
  • Formal safety issues and actions
  • Formal safety issues and actions
  • Safety issues identified through ATSB investigations
  • KPI status of safety issues identified in 2016–17
  • Responses to safety issues identified in 2016–17
  • Safety actions
  • ATSB recommendations closed in 2016–17
  • Safety recommendations released in 2016–17
  • Section 6
  • Features of the ATSB year
  • Aviation stalwart donates historic propeller
  • The ATSB’s contribution to charitable causes
  • ATSB use of RPAS in investigations
  • ATSB presentation at the International Society of Air Safety Investigators
  • The ATSB hosts marine investigators forum
  • The ATSB proactively engaging with industry on transport safety
  • ATSB safety message goes viral
  • The ATSB Evolution Program
  • ICAO audit the ATSB
  • Search for MH370—mapping the seafloor in the search area
  • Section 7
  • Financial statements
  • 2016–17 Financial Statements
  • Section 8
  • Management and accountability
  • Management and accountability
  • The Commission
  • Executive management
  • Business planning and reporting
  • Management of human resources
  • Purchasing
  • Consultants
  • Australian National Audit Office access clauses
  • Exempt contracts
  • Procurement initiatives to support small business
  • Legal services and expenditure
  • External scrutiny and participation
  • Section 9
  • Appendices
  • Appendix A: Other mandatory information
  • Appendix B: Entity Resource Statement 2016–17
  • Appendix C: Glossary
  • Appendix D: List of requirements
  • Subject index

List of Tables

  • Table 1: Results against performance criteria
  • Table 2: Performance at a glance
  • Table 3: ATSB performance against key indicators
  • Table 4: Summary of financial performance and position
  • Table 5: Sonar contacts identified during the underwater search
  • Table 6: Underwater search vessel swings
  • Table 7: Number of safety issues identified in 2016–17
  • Table 8: Status of other safety issues identified in 2016–17
  • Table 9: Aviation critical safety issues identified in 2016–17
  • Table 10: Aviation—Responses to other safety issues identified in 2016–17
  • Table 11: Marine—Responses to safety issues identified in 2016–17
  • Table 13: Number of safety actions released in 2016–17
  • Table 14: Aviation—ATSB recommendations closed in 2016–17
  • Table 15: Marine—ATSB recommendations closed in 2016–17
  • Table 16: Rail—ATSB recommendations closed in 2016–17
  • Table 17: Aviation—Safety recommendations released in 2016–17
  • Table 18: Marine—Safety recommendations released in 2016–17
  • Table 19: Rail—Safety recommendations released in 2016–17
  • Table 20: Safety advisory notices released in 2016–17
  • Table 21: The ATSB’s staffing profile at 30 June 2017
  • Table 23: Freedom of Information activity

List of Figures

  • Figure 1: Winter weather conditions experienced by Dong Hai Jiu 101 in 2016
  • Figure 2: Investigators examine a piece of aircraft debris, 2 July 2016
  • Figure 3: ROV images of verified man-made findings
  • Figure 4: Ministerial visit on board Fugro Equator, January 2017
  • Figure 5: MH370 Tripartite Ministers’ Joint Communique, January 2017
  • Figure 6: Accident site wreckage distribution
  • Figure 7: Aircraft track from Airservices Australia ADS-B data
  • Figure 8: Accident site overview
  • Figure 9: CCTV image showing VH-FVR taxiing inbound at Sydney Airport following the in-flight pitch disconnect
  • Figure 10: Underside of the horizontal stabiliser, with aerodynamic fairings removed
  • Figure 11: Jetstar A320, Beech Aircraft Corporation BE-76 Duchess and Ballina/Byron Gateway Airport
  • Figure 12: Post collision fire, road-train truck (trailers) at Tullamore–Narromine Road railway crossing
  • Figure 13: Derailed train 9T92
  • Figure 14: Skandi Pacific
  • Figure 15: Spirit of Tasmania II after the breakaway
  • Figure 16: Mr Peter Lloyd and ATSB Chief Commissioner Greg Hood
  • Figure 17: Mr Peter Lloyd and the propeller from a Submarine Walrus donated to the ATSB
  • Figure 18: Chief Commissioner Greg Hood at the St Vincent De Paul Society’s CEO Sleepout
  • Figure 19: ATSB investigators training to use a Remotely Piloted Aircraft System
  • Figure 20: Heather Fitzpatrick presenting at the International Society of Air Safety Investigators
  • Figure 21: Participants at the October 2016 MAIFA Conference in Canberra
  • Figure 22: Chief Commissioner Greg Hood with members of the Chief Pilots’ Forum
  • Figure 23: Image showing aftermath of a battery explosion
  • Figure 24: ATSB Staff Meeting
  • Figure 25: ICAO Auditor Thor Thormodsson
  • Figure 26: The differences in resolution between multibeam and satellite-derived bathymetry data
  • Figure 27: Geelvinck Fracture Zone 4,500 m below sea level, fault depth 900 m
  • Figure 28: Main wreckage from in-flight break-up involving PZL Mielec M18A Dromader aircraft
  • Figure 29: Left outboard wing, looking from the wingtip inboard and showing the lower surface of the wing from in-flight break-up involving PZL Mielec M18A Dromader aircraft
  • Figure 30: VH-TSG after recovery: In-flight break-up involving de Havilland DH82A Tiger Moth