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:
- Department of Infrastructure and Regional Development
- Australian Maritime Safety Authority
- Civil Aviation Safety Authority
- National Transport Commission
- Airservices Australia.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
Commission and Executive Management team
Chief Commissioner and Chief Executive Officer
Greg Hood was appointed to the role of Chief Commissioner and Chief Executive Officer of the ATSB on 1 July 2016.
In his time as Chief Commissioner, Greg has overseen a number of significant transport safety investigations and report releases across the three modes of aviation, rail and marine. He has also successfully transitioned the ATSB into its new role as the single national rail safety investigator, bringing to a close a commitment to rail reform initiated by the Council of Australian Governments in 2009.
With more than 35 years of experience across a wide range of operational, training and management roles within Defence and the civil aviation industry, Greg has been well-positioned to drive an innovation agenda at the ATSB. The ATSB’s ‘Evolution Program’ has already seen enhancements to its world-leading practices, including streamlined operations, a multi-disciplinary team approach to transport safety investigations, and the introduction of remotely piloted aircraft to capture evidence following accidents and other safety occurrences.
Prior to his commencement with the ATSB, Greg held the role of Executive General Manager, Air Traffic Control with Airservices Australia. In this position, he was responsible for the management of over 1,300 air traffic management staff, providing services for 11 per cent of the world’s total airspace for more than four million flights annually from 28 air traffic control towers and facilities.
Greg began his career as an air traffic controller in the Royal Australian Air Force in 1980, serving at locations throughout Australia and in the Middle East. In 1990, he moved to the Civil Aviation Authority, a predecessor to what is now Airservices Australia. Greg worked in many locations across the country, and was also involved in the training of new controllers at the University of Tasmania, Launceston.
In 2002, Greg was appointed to lead the Airservices Australia’s management team in Melbourne and then, in 2005, he led the team responsible for the provision of regional air traffic services, including the operation of regional control towers throughout Australia. Greg has also led aspects of the implementation of major air traffic management and technology projects, such as the Australian Advanced Air Traffic System (known as TAAATS), the evolution of safety management systems, and the introduction of user-preferred routes and flex-tracks.
In 2007, Greg joined the Civil Aviation Safety Authority (CASA), where he held the positions of Group General Manager Personnel, Licensing, Education and Training, then Executive Manager Operations. He returned to Airservices Australia during 2013 to take on the role of General Manager Demand and Capacity Management and was appointed as the Executive General Manager of the Air Traffic Control Group later the same year.
Greg has served on the Business Advisory Council for World Vision, is a Fellow of the Royal Aeronautical Society, a Freeman in the Honourable Company of Air Pilots, a Life Member of the Qantas Founders Museum, and past President of Canberra Philharmonic Society. Until being appointed as ATSB’s Chief Commissioner, he was also a Board Member of Safeskies Australia and internationally, Vice-Chair of the steering committee for the Civil Air Navigation Services Organisation’s Operations Standing Committee.
He has a passion for the transport industry in general, and transport safety in particular. He is a glider and powered aircraft pilot.
ATSB commissioners with the executive management team
Noel Hart has over 40 years’ experience in the shipping, oil and gas industries. His qualifications include a Master Mariner Class One qualification, and business administration and MBA certificates.
Mr Hart left his seagoing career to join BP Australia in 1985 and held management positions with BP Shipping in Melbourne, London and Chicago. From 2006 to 2009 he held the position of General Manager of the North West Shelf Shipping Services Company, based in Perth. In his position he was responsible for the safe shipping of liquefied natural gas from north western Australia to Asia and other global customers.
While based in London, Mr Hart was Chairman of the General Purposes Committee of both the Oil Companies International Marine Forum and the Society of International Gas Tanker and Terminal Operators. He also served as a Director of the Middle East Navigation Aids Service, and was an alternate Director of the Alaska Tanker Company and the Marine Preservation Society in the USA, and the Marine Oil Spill Response Centre in Australia.
He has also been Chairman of Maritime Industry Australia Ltd, Australia’s peak maritime association, since 2008.
Chris Manning has over 40 years’ experience in the aviation industry. In the early 1970s he was an air traffic controller. From 1975 until 2008 he was a pilot for Qantas.
Captain Manning flew several Boeing types, gaining a B767 command in 1989. He was a check and training captain throughout the 1990s, and was President of the Australian and International Pilots Association from 1999 until 2002.
From 2003 until his retirement from Qantas in 2008, Captain Manning was Chief Pilot and Group General Manager Flight Operations. He chaired the Australian Aviation Associations Forum from 2008 until 2015. He is a Director of Aerospace Australia Limited (Avalon Airshow), is Chairman of Airport Coordination Australia and is a founding Director of the Australian Aviation Hall of Fame.
Carolyn Walsh has over 30 years’ experience in policy development, regulation and safety management at both the Commonwealth and state levels. She has 15 years’ experience in the transport sector, initially as Executive Director of Strategy in the NSW Office of the Coordinator General of Rail, and then as Chief Executive of the NSW Independent Transport Safety and Reliability Regulator.
In addition to her role as a Commissioner of the ATSB, Ms Walsh is currently Deputy Chair of the National Transport Commission and Vice President of Palliative Care NSW. She is also a member of the audit and risk committees for the City of Sydney, NSW Police Integrity Commission, the Aboriginal Land Council, Western Sydney Local Health District, Office of the Director of Public Prosecutions and NSW Mental Health Commission.
Ms Walsh has specialist expertise in safety (both transport and occupational health and safety), risk management and the regulatory framework governing transport operations in Australia.
Ms Walsh has a Bachelor of Economics degree and is a graduate of the Australian Institute of Company Directors.
EXECUTIVE DIRECTOR Transport Safety
Nat Nagy has been involved in the transport industry since 1996 in a diverse range of operational and leadership roles. He joins the ATSB following a career as a commercial pilot, air traffic controller and, more recently, has held several strategic leadership roles in Airservices Australia including General Manager Demand and Capacity Management, and Manager ATM Service Support. In these roles, he led the workforce in the National Operations Centre, Aeronautical Information Services, Strategic Initiatives Delivery and Flight Procedures Design business areas.
Most recently, Mr Nagy has been a Business Change Manager for Airservices’ Accelerate Program where he delivered a program of technological, organisational and cultural change.
Mr Nagy has tertiary qualifications in Business, and is currently studying for a Master’s Degree in Economics.
PROGRAM DIRECTOR Operational Search for Malaysia Airlines Flight 370 (MH370)
Peter Foley has held the position of Program Director Operational Search for MH370 since May 2014. He is responsible for the ATSB’s operational search activities for missing Malaysia Airlines Flight 370.
Mr Foley joined the ATSB in 1999 after a career at sea as a marine engineer with Australian shipping companies—including ANL Ltd, the Commonwealth shipping line. Since joining the ATSB he has held a number of roles, most recently as General Manager Surface Safety Investigations. This role included responsibility for marine and rail safety investigations, the ATSB’s work on reforms to the National Transport Regulatory framework, and the ATSB’s international programs. He has been responsible for performing and managing a large number of marine and rail investigations, many of them significant. He has represented the ATSB, and Australia, at many international marine and rail industry meetings and conferences.
Mr Foley holds professional qualifications in marine engineering and transport safety investigation, degrees in marine and mechanical engineering and a Graduate Diploma in Business Management.
CHIEF OPERATING OFFICER Corporate Services
Colin McNamara joined the Australian Public Service in October 2004. Prior to this, he served as a General Service Officer in the Australian Army and was awarded the Australian Active Service Medal in 1999.
Prior to his appointment as the ATSB’s Chief Operating Officer, Mr McNamara managed a range of corporate functional areas including Human Resources, Organisational Development, Governance and Major Projects. Over the past 12 months, Mr McNamara has expanded his capabilities through leading a significant change management initiative as the appointed Program Director.
Mr McNamara holds a range of professional qualifications in personnel management and is a professional member of the Australian Human Resources Institute.
Former GENERAL MANAGER Surface Safety Investigations and Technical Analysis
Peter Robertson was the General Manager Surface Safety prior to his retirement in March 2017 after having joined the ATSB in May 2016. He was a Commonwealth public servant for over 30 years after training initially in the RAAF as a pilot.
He has worked in a range of Commonwealth departments, primarily in policy and regulatory areas affecting the aviation, marine, communications and land transport industries, including the Office of Transport Security. Before taking up the General Manager position at the ATSB he was responsible for legal, communications and environmental matters associated with the development of a second major airport for Sydney following a secondment as Deputy Coordinator in the search for missing airliner MH370. He holds the degrees of Bachelor of Arts and Master of Commerce.
Former GENERAL MANAGER Aviation Safety Investigations
Ian Sangston was the General Manager Aviation before his retirement in April 2017. Mr Sangston joined the ATSB as a Senior Transport Safety Investigator (STSI) in April 2002 after 23 years’ service in the Australian Defence Force. In addition to a number of pilot qualifications, he has an undergraduate degree and two master’s degrees in Management Studies and Employment Relations.
Mr Sangston managed a number of high profile investigations as an STSI, and completed a Diploma of Transport Safety Investigation in June 2005. He was promoted to Team Leader, Transport Safety Investigation in mid–2006 and assumed responsibility for the Perth Regional Office. As Team Leader he oversaw more than 80 aviation safety investigations. Mr Sangston was promoted to the General Manager position in August 2009 and was instrumental in the ATSB’s development of a project management approach to investigation management.
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.
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.
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.
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:
Investigations that are likely to involve, at times, significant ATSB and external resources for up to 24 months and are likely to require additional one-off government funding.
Investigations that are likely to involve a large number of ATSB resources, and possibly external resources, and are of a scale and complexity that usually require up to 18 months to complete.
Investigations involving in-the-field activity, several ATSB and possibly external resources, and are of a scale and complexity that usually require up to 12 months to complete.
Less complex investigations that require no more than nine months to complete (some of which are ‘desktop’ exercises requiring no in-field activity) and involve only one or two ATSB staff members.
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.
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.