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Agency overview

The ATSB is Australia’s national transport safety investigation agency. Its primary function is to improve aviation, rail and marine safety. It does this by receiving information about accidents and other safety occurrences, analysing data, and investigating occurrences and safety issues in order to identify and communicate factors that affect, or might affect, transport safety.

The ATSB is part of the Infrastructure and Regional Development portfolio. Within the portfolio are other important transport agencies whose roles are focused on delivering an efficient, sustainable, competitive, safe and secure transport system for all transport users through regulation, financial assistance and safety investigations. These include:

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Purpose

The ATSB is an independent statutory agency of the Australian Government. The ATSB’s purpose is to improve the safety of aviation, rail and marine transport through:

  • the independent investigation of transport accidents and other safety occurrences
  • data recording, analysis and research
  • fostering safety awareness, knowledge and action.

The ATSB performs its functions in accordance with the provisions of the Transport Safety Investigation Act 2003 (TSI Act) and, where applicable, relevant international agreements. The TSI Act makes it clear that the ATSB cannot apportion blame, assist in determining liability or, as a general rule, assist in court proceedings. Its sole focus remains the prevention of future accidents and the improvement of safety.

The ATSB maintains a national information dataset of all safety-related occurrences in aviation and of all accidents and significant safety occurrences in the rail and marine sectors. The information it holds is essential to its capacity to analyse broad safety trends and inform its investigation and safety education work.

Consistent with the Minister for Infrastructure and Transport’s Statement of Expectations for the ATSB, primacy is given to investigations, research, data analysis, and communication and education in relation to operations that involve the travelling public. The ATSB participates in overseas investigations involving Australian-registered aircraft and ships, and cooperates more broadly with its overseas counterparts.

The ATSB has a specific mandate to report publicly on its analysis and investigations, and to conduct public education programs to improve transport safety.

Since 2014, the ATSB has been responsible for the search for missing Malaysia Airlines Flight 370 (MH370). At the decision of the Malaysian, Chinese and Australian Governments, the search was suspended in January 2017 pending credible new evidence becoming available indicating the specific location of the aircraft.

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Our role

Consistent with the Minister’s Statement of Expectations, the ATSB prioritises its work to deliver safety outcomes for the travelling public, as well as those who work in or participate in the aviation, rail and marine transport industries. We do this by:

  • receiving and assessing reports of transport safety matters, including notifications of safety occurrences and confidential reporting
  • independently conducting ‘no-blame’ investigations of accidents and other safety occurrences
  • conducting research into transport statistics and technical issues
  • identifying factors that contribute to accidents and other safety occurrences that affect, or have the potential to affect, transport safety
  • encouraging safety action in response to safety factors by acknowledging action taken by operators, and by issuing safety recommendations and advisory notices
  • raising awareness of safety issues by reporting publicly on investigations and conducting educational programs
  • assisting Australia to meet its international regulatory and safety obligations, and conducting an active program of regional engagement with other transport safety agencies.

Our objectives

In fulfilling our role of improving transport safety and cooperating with others, the ATSB:

  • focuses its resources in the areas that are most likely to result in safety improvements
  • harnesses the expertise and information necessary to perform its safety role
  • conducts impartial, systemic and timely investigations
  • identifies safety issues clearly and objectively without attributing blame or liability
  • ensures the significance of safety issues is clearly understood by all concerned
  • promotes effective safety action.

Organisational change

During 2016–17, the ATSB undertook an organisational change program to deliver the ATSB’s core functions in a more efficient and effective manner. This change program has included an organisational restructure with the establishment of multi-disciplinary teams, rather than having separate teams for the aviation, rail and marine modes of transport. The restructure came into effect in June 2017.

Cooperation with the transport industry

The ATSB works cooperatively with the aviation, rail and marine industries, as well as with transport regulators and governments at state, national and international levels to improve safety standards for all Australians.

The ATSB relies on its ability to build trust and cooperation with the transport industry, and the community, for its success in improving safety. The TSI Act requires the ATSB to cooperate with government agencies, private organisations and individuals who have transport safety functions and responsibilities, or who may be affected by our transport safety activities. The ATSB also cooperates with equivalent national bodies in other countries and international organisations with responsibilities for worldwide transport safety standards.

The ATSB actively targets communications to ensure that transport industry stakeholders understand the importance of no-blame investigations. In order to cultivate a strong reporting culture within the transport industry, the ATSB promotes an appropriate level of confidentiality and protection for sensitive safety information provided to us in the course of our work.

Notifications and reporting

The TSI Act requires any responsible person who has knowledge of any accident (or any immediately reportable matter) to report it as soon as is reasonably practicable.

While the terms of this requirement may seem broad, the Transport Safety Investigation Regulations 2003 provide a list of persons who, by the nature of their qualifications, experience or professional association, would be likely to have knowledge of an immediate or routine reportable matter for their mode of transport. In addition, responsible persons are not required to report a transport safety matter if they believe, on reasonable grounds, that another responsible person has already reported, or is in the process of reporting that matter.

The ATSB maintains a 24-hour service to receive notifications, including a toll-free telephone number (for immediately reportable matters in all modes). In aviation, a secure online notification form for written notifications is available on the ATSB website.

Every year the ATSB’s Notifications team receives over 16,000 notifications of safety occurrences. These are spread over aviation, marine and rail. Inevitably, there are duplicate notifications and many of the notifications submitted concern matters not required to be reported under the TSI Act. Nevertheless, each one is reviewed and recorded.

In 2016–17, the ATSB’s Notifications team received 17,046 aviation notifications in the form of telephone calls, emails, facsimiles, postal letters and website contact. From those, to date, the team has identified 5,482 individual accidents, serious incidents and incidents for the year.

While not all of the reported occurrences are investigated, the details of each occurrence are retained within the ATSB’s occurrence database. These records are a valuable resource, providing a detailed portrait of transport safety in Australia. The ATSB regularly analyses the database to identify emerging trends and issues. The searchable public version of the aviation occurrence database is available on the ATSB website. It contains data from July 2003 onwards. The online database is used by industry, academics, the media and regulators to search and research past events.

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Aviation

The ATSB investigates accidents and other occurrences involving civil aircraft in Australia. The ATSB also analyses data on all notified accidents and incidents. It conducts research into specific matters of concern that emerge from data analysis, and specific incidents or matters that may be referred by other organisations. It does so in a manner consistent with the Convention on International Civil Aviation (Chicago Convention 1944) Aircraft Accident and Incident Investigation (Annex 13).

The ATSB may also investigate serious accidents or incidents involving Australian-registered aircraft overseas, or assist with overseas investigations involving Australian-registered or foreign aircraft if an overseas investigating authority seeks assistance and the ATSB has suitable resources available. The ATSB may also have observer status in important overseas investigations. This provides valuable opportunities to learn from overseas organisations and to benchmark our knowledge and procedures against our counterpart organisations.

The ATSB cooperates with organisations such as CASA, Airservices Australia, the Directorate of Defence Aviation and Air Force Safety, as well as aircraft manufacturers, and operators, who are best placed to improve safety. The ATSB also works collaboratively with the Department of Infrastructure and Regional Development and other safety agencies to assist the Government in implementing transport safety initiatives.

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Marine

The ATSB investigates incidents and accidents involving Australian-registered ships anywhere in the world, and foreign ships in Australian waters or en route to Australian ports.

We work cooperatively with international regulatory authorities, Australia’s maritime regulator, the Australian Maritime Safety Authority (AMSA), the state and territory maritime regulatory authorities, other transport safety investigation agencies and ship owners and operators.

Our marine investigations are conducted in a manner consistent with the International Maritime Organization’s Casualty Investigation Code.

We publish a range of marine transport safety reports and safety educational material, which are distributed to the international maritime community, the International Maritime Organization, educational institutions and maritime administrators in Australia and overseas.

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Rail

The ATSB is the national rail safety investigator following the Council of Australian Governments’ decision through the Intergovernmental Agreement on Rail Safety Regulation and Investigation Reform in 2011. The process was completed with the Queensland Government and the ATSB agreeing to terms for the ATSB to conduct investigations in Queensland from 1 July 2017. Arrangements are now in place for the ATSB to exercise the full extent of its jurisdiction in all states and territories. This includes collecting occurrence information, analysing data, and investigating rail transport safety matters on the metropolitan and regional networks.

The ATSB works cooperatively with organisations such as the Office of the National Rail Safety Regulator (ONRSR) and rail operators—all of whom share a responsibility to improve safety. The ATSB also has collaboration agreements with the New South Wales and Victorian state safety investigation organisations.

Technical analysis

The ATSB maintains an in-house technical analysis capability to examine, extract and analyse the physical and recorded evidence associated with safety occurrences from all modes of transport. Specialists in forensic engineering, failure analysis, data recovery and systems analysis work with other ATSB investigators, and external stakeholders, to provide a detailed insight into the often complex set of factors that underlie many transport safety occurrences. The team maintains a centre of excellence for rail, marine and flight data ‘black box’ analysis in the Asia–Pacific region—providing our international neighbours with technical advice, support and assistance in occurrence investigation and capability development.

As of June 2017, members of the Technical Analysis team were integrated with other transport safety investigation staff as part of the ATSB’s multi-disciplinary teams, consistent with the agency’s organisational change program.

Short investigations

In addition to its more complex investigations, the ATSB undertakes short, office-based investigations of less complex safety occurrences. Our capacity to conduct a large number of these short investigations provides us with the opportunity to deliver safety messages, and for industry participants to learn from the experience of others. Although many of these investigations examine occurrences that are common, and for which the underlying factors are well known, they also enhance the quality and completeness of the occurrence data held by the ATSB. As a result, a more extensive database expands our ability to identify situations where more detailed investigation may be warranted.

Short investigation reports detail the information gathered from individuals or organisations involved in the occurrence, the circumstances, a short safety analysis, the findings, and what safety action may have been taken or identified as a result.

As of June 2017, members of the Short Investigation team were integrated with other transport safety investigation staff as part of the ATSB’s multi-disciplinary teams, consistent with the agency’s organisational change program.

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Confidential reporting (REPCON)

The ATSB operates the voluntary and confidential reporting scheme (REPCON) for the aviation, rail and marine industries. Any person within these industries, or member of the travelling public, may submit a REPCON report of a reportable safety concern. The scheme is designed to capture safety concerns—including unsafe practices, procedures and risk controls within an organisation, or affecting part of the industry.

Each reported safety concern is de-identified by the ATSB by removing all personal details concerning the reporter and any individual named in the report. This de-identified text is passed back to the reporter who must authorise the content before the REPCON can proceed further. The de-identified text is then forwarded to the relevant organisation that is best placed to address the safety concern. The organisation’s response will then be forwarded to the relevant regulator for further action as deemed necessary.

The aim of the REPCON scheme is to ensure safety action is taken to address the reported safety concerns. This can include variations to standards, orders, practices and procedures, or an education campaign. The ATSB may use the de-identified version of the reported safety concern to issue an information brief, or an alert bulletin, to whichever person or organisation is best placed to take safety action in response to the safety concern. The ATSB publishes the outcome of each REPCON on its website.

Research and data analysis

The ATSB maintains an aviation occurrence database which is utilised for data analysis and research. The ATSB’s interest is in ensuring the safety information in its possession is interrogated to identify and communicate safety issues. The work provides an opportunity to detect trends and identify safety issues across many, rather than individual, occurrences. Research and data analysis also contributes to the ATSB’s decision-making about which occurrences to investigate.

The ATSB maintains a large database of occurrence information in aviation. The ATSB’s dataset in marine is limited to occurrence information on accidents and serious incidents reportable to the ATSB for interstate and overseas shipping. In rail, the ATSB has not had access to the national rail occurrence database held by the ONRSR. However, the ATSB is expecting to access a copy of this dataset by late 2017.

The ATSB produces official Australian aviation occurrence statistics each year, and in-depth analysis of issues and trend monitoring of all aviation occurrences, for the benefit of government, industry and the public.

As of June 2017, the Research and Data Analysis team were integrated with other transport safety investigation staff as part of the ATSB’s multi-disciplinary teams, consistent with the agency’s organisational change program.

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International cooperation

The ATSB is committed to promoting engagement with its international counterpart agencies and relevant multilateral organisations. It works to assist Australia’s regional neighbours through international agreements and participation in intergovernmental programs. It actively supports initiatives to build aviation and marine safety investigation capability in the Asia–Pacific region.

The philosophy underpinning the ATSB’s regional engagement is one of cooperation and mutual respect. The strategic intent is to improve transport safety for the benefit of our regional neighbours and the Australian travelling public.

The ATSB is actively involved in the work of the International Civil Aviation Organization (ICAO), the International Maritime Organization (IMO) and the Marine Accident Investigators Forum in Asia (MAIFA).

ATSB organisational structure

ATSB organisational structure

Commission and Executive Management team

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ATSB commissioners with the executive management team

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Outcome and program structure

Program 1.1 objective

The ATSB will work actively with the aviation, marine and rail industries, transport regulators and governments at a state, national and international level to improve transport safety standards for all Australians, particularly the travelling public. Investigations and related activities seek to raise awareness of identified safety issues and to encourage stakeholders to implement actions to improve future safety.

There are three core functions which arise from the ATSB’s functions under the Transport Safety Investigation Act 2003 (TSI Act):

1. Independent ‘no-blame’ investigation of transport accidents and other safety occurrences

Independent investigations that are selective and systemic, and which focus on future safety rather than on blame, increase stakeholder awareness and action on safety issues, and foster industry and public confidence in the transport system.

2. Safety data recording, analysis and research

Timely receipt and assessment of transport accident and other safety occurrence notifications allows the ATSB to identify and refer safety issues at the earliest opportunity. The maintenance and analysis of a body of safety information (including transport safety data and research and investigation reports) enables stakeholders and researchers to gain a better understanding of safety trends and safety issues.

3. Fostering safety awareness, knowledge and action

Awareness and understanding of transport safety issues is increased through a range of activities, including consultation, education, and the promulgation of research and investigation findings and recommendations. These contribute to the national and international body of safety knowledge and foster action for the improvement of safety systems and operations.

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How the ATSB reports

Section 63A of the TSI Act requires that:

The annual report prepared by the Chief Executive Officer and provided to the Minister under section 46 of the Public Governance, Performance and Accountability Act 2013 (PGPA Act) for a period must include the following:

1. prescribed particulars of transport safety matters investigated by the ATSB during the period

2. a description of investigations conducted by the ATSB during the period that the Chief Commissioner considers raise significant issues in transport safety.

The ATSB observes and complies with Resource Management Guide No 135–Annual reports for non-corporate Commonwealth entities issued by the Department of Finance. This report is based on the guidance for 2016–17 published in May 2017.

This Annual Report details the ATSB’s performance against the program objectives, deliverables and key performance indicators published in the Infrastructure and Regional Development Portfolio Budget Statements 2016–17. The ATSB annual report also includes audited financial statements in accordance with the PGPA Act.

Priorities for investigation

The ATSB’s highest priority is to investigate accidents and safety occurrences that have the greatest potential to deliver improved transport safety for the travelling public.

The ATSB is not resourced to investigate every single accident or incident that is reported, but allocates priorities within the transport modes to ensure that investigation effort achieves the best outcomes for safety improvement. The ATSB recognises that there is often more to be learned from serious incidents and patterns of incidents, and gives focus to these investigations, as well as specific accident investigations.

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Three ways to action

The TSI Act requires specified people and organisations to report to the ATSB on a range of safety occurrences (called ‘reportable matters’). Reportable matters are defined in the Transport Safety Investigation Regulations 2003. In principle, the ATSB can investigate any of these reportable matters. In practice, they are actioned in one of three ways to contribute to the ATSB’s functions:

1. A report of an occurrence that suggests a safety issue may exist will be investigated immediately. Investigations may lead to the identification/confirmation of the safety issue and evaluation of its significance. It will then set out the case for safety action to be taken in response.

2. A report of an occurrence that does not warrant full investigation may warrant additional fact gathering for future safety analysis, to identify safety issues or trends.

3. Basic details of an occurrence, based primarily on the details provided in the initial occurrence notification, can be recorded in the ATSB’s occurrence database to be used in future safety analysis to identify safety issues and trends.

Note: In the third approach, the occurrence is not investigated immediately, but may be the subject of a future safety issue or research investigation.

Aviation broad hierarchy

The ATSB allocates its investigation resources consistent with the following broad hierarchy of aviation operation types:

1. passenger transport—large aircraft

2. passenger transport—small aircraft:

a. regular public transport and charter on small aircraft

b. humanitarian aerial work (for example, the Royal Flying Doctor Service, search and rescue flights)

3. commercial (fare-paying and recreation—for example, joy flights)

4. aerial work with participating passengers (for example, news reporters, geological surveys)

5. flying training

6. other aerial work:

a. non-passenger carrying work (for example, agriculture, cargo)

b. private transport or personal business

7. high-risk personal recreation/sports aviation/experimental aircraft operations.

The ATSB endeavours to investigate all fatal accidents involving VH-registered powered aircraft subject to the potential transport safety learnings and resource availability.

Marine broad hierarchy

The ATSB allocates its investigative resources consistent with the following broad hierarchy of marine operation types:

1. passenger operations

2. freight and other commercial operations

3. non-commercial operations.

Rail broad hierarchy

The ATSB allocates its investigative resources consistent with the following hierarchy of rail operation types:

1. mainline operations that impact on passenger service

2. freight and other commercial operations

3. non-commercial operations.

Level of response

The level of investigative response is determined by resource availability and factors such as those detailed below. These factors (expressed in no particular order) may vary in the degree to which they influence the ATSB’s decisions to investigate and respond. Factors include:

  • the anticipated safety value of an investigation, including the likelihood of furthering the understanding of the scope and impact of any safety system failures
  • the likelihood of safety action arising from the investigation, particularly of national or global significance
  • the existence and extent of fatalities/serious injuries and/or structural damage to transport vehicles or other infrastructure
  • the obligations or recommendations under international conventions and codes
  • the nature and extent of public interest—in particular, the potential impact on public confidence in the safety of the transport system
  • the existence of supporting evidence, or requirements, to conduct a special investigation based on trends
  • the relevance to identified and target safety programs
  • the extent of resources available, and projected to be available, in the event of conflicting priorities
  • the risks associated with not investigating—including consideration of whether, in the absence of an ATSB investigation, a credible safety investigation by another party is likely
  • the timeliness of notification
  • the training benefit for ATSB investigators.

The objective of the classification process is to quickly identify, allocate resources and appropriately manage occurrences that:

  • require detailed investigation
  • need to be recorded by the ATSB for future research and statistical analysis
  • need to be passed to other agencies for further action
  • do not contribute to transport safety.

Investigation levels

The ATSB’s response to reported safety matters is classified by the level of resources and/or complexity and time they require.

The following safety investigation levels were used by the ATSB in 2016–17:

Major investigations

Investigations that are likely to involve, at times, significant ATSB and external resources for up to 24 months and are likely to require additional one-off government funding.

Level 1

Investigations that are likely to involve a large number of ATSB resources, and possibly external resources, and are of a scale and complexity that usually require up to 18 months to complete.

Level 2

Investigations involving in-the-field activity, several ATSB and possibly external resources, and are of a scale and complexity that usually require up to 12 months to complete.

Level 3

Less complex investigations that require no more than nine months to complete (some of which are ‘desktop’ exercises requiring no in-field activity) and involve only one or two ATSB staff members.

Level 4

Investigations that are less complex and require no more than five months to complete (in some cases, after initial in-the-field or other investigation activity, the investigation level may be changed or the investigation discontinued if it is determined that there is no safety value to be gained from continuing the investigation). These investigations generally involve only one or two ATSB staff members.

Level 5

Short investigations are limited-scope factual investigations that result in a short summary report of two to eight pages. Short investigations are generally completed within four months or sooner, and are usually published in a monthly bulletin. They usually require only one ATSB staff member.