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Report on performance

This section reviews the ATSB's results against the performance criteria and deliverables set out in the Portfolio Budget Statements 2016–17 and the ATSB Corporate Plan 2016–17. The ATSB's effectiveness in achieving planned outcomes during 2016–17 is also reviewed here.

Annual performance statement

I, as the accountable authority of the Australian Transport Safety Bureau, present the annual performance statement of the Australian Transport Safety Bureau for the year ended 30 June 2017, as required under paragraph 39(1)(a) of the Public Governance, Performance and Accountability Act 2013 (PGPA Act). In my opinion, this annual performance statement is based on properly maintained records, accurately reflects the performance of the entity, and complies with subsection 39(2) of the PGPA Act.

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Greg Hood Chief Executive Officer

22 September 2017

Table 1: Results against performance criteria

Purpose

As set out in the Portfolio Budget Statements 2016–17 and the ATSB Corporate Plan 2016–17, the ATSB's purpose is to improve the safety of, and public confidence in, aviation, marine and rail transport through:

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

Performance criterion

Result

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

There was one critical safety issue (aviation) identified in 2016–17. At the time of publication, safety action was still pending.

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

67% of all other safety issues identified by ATSB investigation reports were addressed in 2016–17.

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

32% of complex investigation reports were published within 12 months during 2016–17.

90% of short investigation reports are completed within four months. Note: the criterion was changed from two months to four months during the 2016–17 Portfolio Additional Estimates.

88% of short investigation reports were completed within four months during 2016–17.

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

This survey is only conducted every second year and was not done during 2016–17.

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

57% of safety action was undertaken by stakeholders to address valid safety concerns identified by confidential reports.

Analysis of performance

The ATSB operates in an environment of continuing growth and emerging trends across the aviation, rail and marine transport sectors. The Government's recent budget measure 'improving transport safety' will assist the ATSB in maintaining a sustainable resource base and addressing the changing operating environment. Prior to this budget measure taking effect, the ATSB's workforce capability was more limited.

The ATSB has continued to meet its key deliverables in terms of the number of investigation reports completed and published per year. However, it is evident the ATSB has not been able to complete these reports within the set timeframes with its workforce capability limitations. The budget measure and the ATSB's organisational change program, with its focus on enhancing the efficiency and effectiveness of investigations going forward, are expected to put the ATSB back on track with meeting its deliverable targets.

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

Performance at a glance

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Table 2: Performance at a glance

Deliverable

Year

Number completed1

Per cent completed

Complex investigations

Per cent completed within 12 months

Aviation

2016–17

39

31%

2015–16

44

18%

2014–15

39

41%

Marine

2016–17

5

40%

2015–16

7

14%

2014–15

5

60%

Rail

2016–17

15

33%

2015–16

19

58%

2014–15

20

40%

Short investigations

Per cent completed within 4 months

All modes

2016–17

110

88%

2015–16

90

81%

2014–15

98

77%

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Key results

Table 3 summarises the ATSB's performance against key indicators published in the Portfolio Budget Statements 2016–17.

Table 3: ATSB performance against key indicators

Target

Performance

Page

Key performance indicators

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

  • critical safety issues

100% addressed

One identified – safety action pending

  • all other safety issues.

70% addressed

63% addressed

Page 94

Complex investigation reports are published within 12 months.

90% published within 12 months.

32%

Page 40

Short investigation reports are completed within four months.

90% completed within four months.

88%

Page 40

Stakeholder awareness is raised as a result of investigation, research and analysis of findings and through safety education activities as measured through a biennial survey, scored on a 5-point rating scale.

Rating of 4 or above.

Not applicable in 2016–17. Survey conducted once every two years.

N/A

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

70% actioned

57%

Page 41

Deliverables

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

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

83%

Page 41

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

26%

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

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

55%

Page 41

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

84%

Page 41

Complete and publish investigations.

Up to 60 complex investigations.

59 complex investigation reports published.

Page 40

Up to 120 short investigations.

110 short investigations completed.

Page 40

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

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

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

One statistics report plus three other research reports published.

No trend monitoring report published.

Page 41

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

One major exercise per annum.

Participation in three exercises.

Page 45

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

Delivery of approved projects within program funding allocation.

See detailed report.

Page 52

Assist the Malaysian Government with its investigation into the disappearance of Malaysia Airlines Flight 370 (MH370) in accordance with Annex 13 to the Convention on International Civil Aviation. Work with primary and secondary stakeholders in relation to decisions made by governments regarding the search and/or potential recovery operations of MH370.

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

Continue to assist the Malaysian investigation as an Accredited Representative.

See detailed report.

Page 59

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

This section describes the ATSB's performance against the deliverables relating to the ATSB's role as the independent 'no-blame' transport safety investigator, as published on page 116 of the Portfolio Budget Statements 2016–17.

Deliverables

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

Aviation investigations

In 2016–17, the ATSB initiated 38 complex safety investigations—29 of which were occurrence investigations—from 17,046 notifications (of these notifications, 5,482 have been classified as aviation occurrences).

During this reporting period, 39 complex investigations were completed (comprising 27 occurrence investigations, 12 external investigations, three research/education investigations and 0 safety issue investigations). Of the 39 complex investigations, 12 were completed within 12 months.

As at 30 June 2017 there were 69 ongoing complex aviation investigations.

Marine investigations

In 2016–17, the ATSB initiated four complex marine transport safety investigations from a total of 136 accidents and incidents. In this time period five complex investigations were completed (four were occurrence investigations and one was assistance to an external organisation), two of which were completed within 12 months.

As at 30 June 2017, the ATSB continues to investigate six marine occurrences (as complex investigations).

Rail investigations

In 2016–17, the ATSB initiated four complex rail safety investigations (all occurrence investigations) from 374 notifications of immediately reportable matters.

The ATSB completed 15 complex rail investigations in 2016–17. Of the 15 investigations, five were completed within 12 months.

As at 30 June 2017, the ATSB continues to investigate 20 complex rail safety occurrences (complex investigations) and one safety issue investigation.

Short investigations

In 2016–17, the ATSB initiated 119 short investigations—113 in aviation, three in marine and three in rail.

During this period, 108 aviation short occurrence investigations were completed (96 within four months). Also completed were one marine and one rail short occurrence investigation.

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Research and statistics

There were three educational research publications completed in 2016–17. These were:

In 2016–17, the ATSB published one aviation statistical report, the annual Aviation Occurrence Statistics: 2006 to 2015.

Details on the ATSB's research reports are provided on pages 46–51—Safety data recording, analysis and research.

Reporting

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

  • one day for occurrences being investigated
  • ten days for summaries of other incidents.

Of 152 occurrences investigated, 126 (83 per cent) were processed with summaries published on the ATSB website within one working day of the start of the investigation.

In 2016–17, 26 per cent of aviation occurrence notifications were processed and ready for publication within ten working days. The average time for processing was 43 working days.

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Confidential reporting

In the 2016–17 year, the ATSB's Confidential Reporting Scheme (REPCON) received 129 notifications (of which 43 were classified as REPCONs). Of these 129 notifications, 109 concerned aviation (34 REPCONs), 17 concerned rail (eight REPCONs) and three concerned marine (one of which was a REPCON).

Of the 44 REPCON reports completed in 2016–17, 23 (52 per cent) resulted in safety action by stakeholders.

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

Aviation

  • The reporter expressed a safety concern that a hands-on course on how to conduct an engine overhaul is being presented to association members by people without the required knowledge to teach and perform these tasks safely. As a result of this report a complete review of all training materials endorsed or perceived to be endorsed by the organisation was conducted. They also defined which courses they would deliver and are preparing a standard to assess all training courses and their approved trainers prior to delivery.
  • The reporter advised that on a number of occasions they have observed Cessna 208s landing/departing with the tail stand (pogo stick) attached. The reporter advised that as this is occurring on a regular basis, there could be a systemic problem with the pre-flight (walk around) procedure. The operator advised that they checked with all C208 crews and no issues have been reported. They have a mirror installed on the left-hand wing of company C208s to allow the aircrew to physically inspect the outside of the aircraft by sight from the pilot's seat, prior to starting up. Additionally, the first component of their pre-taxi checks on their mandatory checklist states 'Pod doors, hatches, tail stand'. As a result of this report, the operator has found some additional suggestions towards several pre-flight and pre-taxing procedures that relate, not only to tail stand use, but also other areas, and has now implemented some small but useful relevant improvements to the operation, with the goal of making procedures even more robust.
  • The reporter expressed a safety concern related to the missed approach procedure for the RNAV-E approach at Bunbury Airport. The reporter advised that there is an unlit mast in the vicinity. The missed approach procedure takes an aircraft in close proximity to the mast, but does not specify an altitude which an aircraft must meet by a distance from the airport to ensure separation with the mast. Airservices Australia advised that the missed approach procedure provides more than the minimum required obstacle clearance when an aircraft is overhead the mast. As a result of this report, the Civil Aviation Safety Authority (CASA) reviewed the REPCON and suggested that Airservices Australia explore a different missed approach procedure. They also advised that the tower is reported at different heights on different charts. Airservices Australia advised that the procedure is due for review in 2017 and they will consider the feedback in their revalidation and investigate the tower height discrepancies. A Notice To Airmen was published to address the issue.

Marine

  • The reporter expressed a safety concern related to the time it is taking for the Port Authority to implement a Fatigue Risk Management system for pilots. The reporter advised that the current fatigue management system was designed using the InterDynamics FAID Fatigue Assessment Tool and accepted a FAID fatigue score of 80 as being safe. This score is the equivalent of a blood alcohol (BAC) reading of 0.05 [grams/100 millilitres] but the Port Authority of [de-identified] Drug and Alcohol policy now has an allowable limit of only 0.02 BAC. Early in 2015, the pilots and the Port Authority met and agreed that a new policy was required. The new fatigue management policy is now available and over October and November of 2015 all Port Authority employees received training in how to apply it. The reporter did not believe the current roster rules were sufficient to meet the requirements of the Pilotage Code. The reporter did not believe the proposed new roster rules were sufficient unless they were integrated into a proper fatigue management system.

    The operator advised that discussions commenced in late 2015 and some progress was made, including consultation, engagement of specialist consultants, pilot survey, pilot training in the area of fatigue management, and the development of a draft policy. However, as a result of change in personnel, this process stalled for a number of months. Recently, the process has been reinvigorated by both the Port Authority and the pilot group.

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Rail

  • The reporter advised that recently two drivers received mild electric shocks while operating the electronic ground based warning system (GBWS) within the [de-identified]. The GBWS is a system to warn of train movements without the requirement for the use of a train horn when entering and leaving the stabling yard. The GBWS control panel is located on raised metal platforms, which allow for easier and safer crew entry and exit from the crew compartment within the yard. The panel is contained within a stainless steel enclosure, which should be water tight and electrically safe. To date, the train crews have not been officially notified if there are electrically live platforms at the yard and what precautions they should be taking. The operator had contacted the Office of the National Rail Safety Regulator (ONRSR) in relation to the issues. As a result of this report, the ONRSR made further enquiries with the operator and continued to monitor the close out of outstanding actions.
  • The reporter advised that drivers employed by the operator are being rostered for long hours and are not receiving the minimum breaks between shifts. The Rail Industry Safety and Standards Board (RISSB) published fatigue risk management guidelines which advise 'Recognition of the risk associated with long commutes by both individual workers and their organisations is important, but management of the risk is best left to the individual and their immediate supervisor.' Employees who have a significant commute between their home and workplace are not having this taken into consideration in the breaks between shifts. The reporter also advised that the roster can be adjusted on a daily basis and the shifts can be changed by adjusting the start time. This does not allow the drivers the certainty required to prepare for a busy 12-hour driving shift. ONRSR has undertaken inspections of the operator's fatigue management processes, and has verified that the operator has processes in place to manage fatigue for its locomotive crews. However, the inspections have identified deficiencies within these processes. The ONRSR is monitoring the operator's corrective actions to improve its systems and processes. The ONRSR will continue to monitor the operator through inspections and audits during the year in order to ensure that the systems and processes remain effective and continue to be followed, taking into consideration the specific issues identified within the REPCON report as regulatory intelligence.
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Technical analysis

The ATSB's technical analysis capability staff maintain support and readiness for the detailed examination of physical evidence and the recovery and download of recorded data from a variety of damaged and undamaged sources across the aviation, rail and marine transport modes.

In the past year, these staff continued to expend considerable resources, providing data and debris analysis in support of the ATSB's ongoing assistance to Malaysia, in the search for MH370.

Also internationally, the ATSB's recorder data experts provided technical and developmental support to the National Transportation Safety Committee of Indonesia through the Indonesia Transport Safety Assistance Package (ITSAP). Assistance was also provided to the Transport Accident Investigation Commission of New Zealand in the download of a cockpit voice recorder from an ATR72 aircraft involved in an emergency landing at Palmerston, New Zealand.

As an example of the ATSB's technical analysis capability, in the ATSB investigation AO-2017-032, involving a SAAB 340 propeller separation event, staff conducted a trajectory analysis, enabling the separated propeller to be located in bushland. This was followed by our materials failure experts identifying the source of the failure and facilitating safety action from the component manufacturer.

In addition to supporting the ATSB investigations, technical analysis staff have provided assistance to CASA, Recreational Aviation Australia, and various  state coroners in transport safety-related matters.

Preparedness for a major accident

Maintenance of the ATSB's operational capability and readiness extends directly to the agency's preparedness for undertaking and managing all aspects of a major transport safety investigation. The ATSB actively engages with the transport industry to develop an awareness of the ATSB's role, and to participate in practical exercises involving hypothetical transport accidents—aimed at directly testing the effectiveness and scope of the ATSB's response arrangements.

In June 2017, the ATSB participated in Exercise Southern Cross 2017—a full-deployment accident response exercise conducted by Brisbane Airport. As part of the exercise, the ATSB deployed an Immediate Response Team to the Brisbane Airport Emergency Operations Centre and the exercise accident site. The ATSB's Accident Response Centre in Canberra was activated, as was a simulated Forward Command Centre.

The ATSB's support of the Malaysian Government's investigation into MH370 has provided an opportunity to review and evaluate the planning and response for a major accident involving an Australian-registered aircraft.

These activities have provided valuable input into the ATSB's continuous and ongoing improvement program for assuring our readiness to mount a timely and effective investigative response to a major transport accident.

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Implementing the ATSB's expanded role in rail

In August 2011, the Council of Australian Governments (COAG) signed the Intergovernmental Agreement on Rail Safety Regulation and Investigation Reform, with a view to introducing consistent national regulation and investigation capabilities. Those reforms were subsequently agreed across New South Wales, Tasmania, South Australia and the Northern Territory in 2013, Victoria in 2014, and Western Australia in 2015.

In late 2015, the Queensland Government advised of its intention to participate in the national regulatory and investigation reforms. The Rail Safety National Law (Queensland) Act 2017 covering rail safety regulation was assented to in March 2017. Arrangements were finalised for the ATSB to conduct all rail safety investigations in Queensland under the Transport Safety Investigation Act 2003 from 1 July 2017.

Cooperation with the NSW Office of Transport Safety Investigations (OTSI) and Victoria's Chief Investigator of Transport Safety (CITS) has been strong and productive. Through an ongoing program of ATSB-provided training and refresher programs, staff from both agencies have developed a strong working knowledge, along with practical application, of the ATSB's policies, procedures and legislation.

The ATSB and Victoria's CITS have advanced the relationship further, with CITS commencing a marine investigation (MO-2017-003) in collaboration with the ATSB under the Transport Safety Investigation Act 2003.

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Safety data recording, analysis and research

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

This section describes the ATSB's performance against the deliverables set out on page 116 of the Portfolio Budget Statements 2016–17.

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Deliverables

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

In 2016–17, the ATSB continued to analyse occurrence data held in its aviation safety occurrence database as part of Australia's international obligation to determine if preventative safety measures are required.

In addition to these deliverables, the ATSB research and analysis staff continued to support active aviation occurrence investigations during 2016–17. Significant data analysis was completed for over 30 aviation occurrence investigations during the financial year. This work helped to determine the investigation scope, inform investigation conclusions and safety issue risk assessments, and document past occurrences of similar incidents.

The ATSB published four research investigation reports during 2016–17.

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Australian aviation wildlife strike statistics: 2006 to 2015 (AR-2016-063)

Occurrences involving aircraft striking wildlife, particularly birds, are the most common aviation occurrence reported to the ATSB. Strikes with birds continue to be a potential safety risk and present a significant economic risk for aerodrome and airline operators. The aim of the ATSB's statistical report series is to provide information to pilots, aerodrome and airline operators, regulators, and other aviation industry participants to assist them with managing the risks associated with bird and animal strikes. This report updates the last edition published in 2014 with data from 2014–2015.

Between 2006 and 2015, there were 16,069 birdstrikes reported to the ATSB, most of which involved high capacity air transport aircraft. Both the number and rate of birdstrikes per 10,000 movements in high capacity operations have increased markedly in the two year period 2014­–2015. In contrast, the number of birdstrikes in low capacity operations and general aviation has remained relatively consistent. In the two years between 2013 and 2015, the rates for six of the ten major airports have increased relative to ten year averages. The largest increases in the rate of birdstrikes were observed at Cairns, Canberra, Darwin, Gold Coast and Sydney.

Domestic high capacity aircraft were those most often involved in birdstrikes, and the birdstrike rate per aircraft movement for these aircraft was significantly higher than all other categories. The number of engine bird ingestions for high capacity air transport operations had been increasing until 2011, but has since decreased slightly. Still, about one in ten birdstrikes for turbofan aircraft involved a bird ingested into an engine.

The four most commonly struck types of flying animal in the 2014 to 2015 period were: bats/flying foxes, swallow/martins, kites and lapwings/plovers. Swallows and martins had the most significant increase in the number of reported birdstrikes per year in the last two years, with these species being involved in an average of 96 birdstrikes per year for 2014 and 2015 compared with 65 per year on average across the entire ten-year reporting period. Galahs were more commonly involved in birdstrikes of multiple birds, with more than 38 per cent of galah strikes involving more than one galah. However, larger birds were more likely to result in aircraft damage.

This report presents a new species mass analysis which estimates that over the ten years between 2006 and 2015, 766 kg of flying animals were struck per year by aircraft in Australia. Additionally, for every 1 kg increase in animal mass, the likelihood of a birdstrike causing damage increases by 12.5 per cent.

Compared to birdstrikes, ground-based animal strikes are relatively rare. The most common animals involved were hares and rabbits, kangaroos, wallabies, and dogs/foxes. Damaging animal strikes mostly involved kangaroos, wallabies and livestock.

The ATSB research investigation report, Australian aviation wildlife strike statistics: 2006 to 2015 (AR-2016-063), is available from the ATSB website at www.atsb.gov.au

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Aviation Occurrence Statistics: 2006 to 2015 (AR-2016-122)

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

In 2015, Australia had 31 fatalities and 32 serious injuries—28 aircraft were involved in fatal accidents and a further 28 in an accident resulting in serious injuries. There was a total of 227 aircraft involved in accidents, and 185 involved in serious incidents (indicating an accident nearly occurred).

  • Commercial air transport had one fatality from nine accidents.
  • General aviation had 12 fatalities from 130 accidents.
  • Recreational aviation had 18 fatalities from 76 accidents.

For commercial air transport, 2015 had the lowest number of accidents in the study period (2006–2015). Of the 19 fatalities (2006–2015), 17 involved aircraft conducting charter operations.

The majority of fatalities in the ten-year period occurred within general aviation. Around 20 per cent of fatal accidents resulted from a loss of control.

Growth in recreational (non-VH) flying and improving awareness of reporting requirements, led to more than a tenfold increase in the number of recreational safety incidents reported to the ATSB between 2006–2015.

The number of remotely piloted aircraft accidents and incidents increased significantly—from 14 occurrences within eight years (2006–2013) to 37 within the last two years of the study period (2014–2015).

From 2006 to 2014 (activity data was not available for 2015), recreational aircraft, search and rescue, private/business and sports aviation, and aerial agriculture operation types had the highest fatal accident rates (per hours flown). For all accidents, the highest accident rates occurred with recreational aeroplanes, followed by aerial agriculture, private/business and sport aviation, and recreational gyrocopters.

  • Around 40 per cent of all recreational gyrocopter accidents resulted in fatalities and almost one-quarter of weight shift aircraft accidents were fatal.
  • The highest general aviation accident rate in the study period was in 2014. However, that year also had the lowest fatal accident rate.
  • In 2014, the flying training accident rate was more than double that of any year in the previous eight.

Aviation Occurrence Statistics: 2006 to 2015 (AR-2016-122) is available on the ATSB website at www.atsb.gov.au

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Aerial application safety: 2015–2016 year in review (AR-2016-022)

Aerial application operations encounter different risks compared to other aviation sectors because these pilots work at very low levels. Working at these levels means that pilots encounter more hazards, such as powerlines, trees and poles. When working at these levels, pilots have a high workload to navigate these hazards, and have a shorter reaction time if they encounter an issue and need to respond accordingly. Recent investigations by the ATSB have also highlighted the risks during an operation if the aircraft is overloaded, such as airframe damage. This is the second report in a series of publications on aerial application (including aerial spraying, spreading and fire control). This report covered accidents and serious incidents reported to the ATSB between May 2015 and April 2016 to coincide with the previous operational year.

Between May 2015 and April 2016, there were 29 accidents and serious incidents reported to the ATSB. Of these, 16 were accidents and 13 were serious incidents (near accidents). The most prevalent occurrence was wirestrike, comprising nearly 40 per cent of all occurrences (11 occurrences). Other types of accidents and serious incidents were engine failure or malfunction (six), collision with terrain (three), controlled flight into terrain (two) and runway excursions (two). Safety factors relating to human factors were most prevalent, in particular monitoring and checking, which contributed to 35 per cent of occurrences.

Given the nature of these operations, there are strategies to lower risks. The Aerial Application Association of Australia (AAAA) has published strategies in their pilots' manual that can be applied to managing wirestrikes and engine failures. One strategy is planning. In regards to wirestrikes, planning involves knowing the location of wires in the area and organising the spraying pattern accordingly. Planning to manage the event of an engine failure includes noting potentially safe areas to land, such as open fields. Another strategy is to maintain focus during the task, such as continually reminding yourself of the presence of wires, and in the case of engine failure, focusing on following procedures will assist in avoiding further damage.

Aerial application safety: 2015–2016 year in review (AR-2016-022) is available on the ATSB website at www.atsb.gov.au

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A safety analysis of remotely piloted aircraft systems 2012 to 2016: A rapid growth and safety implications for traditional aviation (AR-2017-016)

The growth in the number of remotely piloted aircraft systems (RPAS) in Australia is increasing exponentially. This presents an emerging and insufficiently understood transport safety risk.

Through this research report, the ATSB aims to better understand the implications for transport safety associated with the expected continual growth in the number of RPAS in Australia.

Although accurate assessments of the number of RPAS in Australia is not possible, using proxy data, it is clear that the number of RPAS in Australia is rapidly growing each year. Compared to 2016, there will be a possible doubling in the number of systems in Australia by the end of 2017.

In association with the level of growth, the number of RPAS-related safety occurrences reported to the ATSB has increased exponentially during the 2012 to 2016 period.

About half of the 180 occurrences from 2012 to 2016 involved near encounters with manned aircraft. Over 60 per cent of all reported RPAS near encounters (108 occurrences) occurred in 2016 (69 occurrences). Statistical models forecast a 75 per cent increase in the number of near encounters in 2017. Most occur in capital cities, Sydney in particular, and mostly above 1,000 ft above mean sea level (AMSL).

To date, there have been no reported collisions between RPAS and manned aircraft in Australia.

The next most common type of occurrence involved collisions with terrain, accounting for 52 occurrences between 2012 and 2016, 35 of which occurred in 2016. Terrain collisions were most commonly associated with a loss of control (about 40 per cent), a bird striking the RPAS (about 10 per cent), or engine failure or malfunction (10 per cent).

The consequences of collisions between RPAS and manned aircraft are not yet fully understood. Worldwide, there have been five known collisions. Three of these resulted in no damage beyond scratches. However, one collision with a sport bi-plane in the United States of America (USA) in 2010 resulted in a crushed wing. Fortunately, the aircraft landed safely. Less fortunately, a Grob G 109B motor glider had a wing broken by an RPAS collision in 1997 in Germany, resulting in fatal injury to the two people on board.

Due to the rarity of actual collisions, and very minimal actual testing, mathematical models have been used to predict damage expected from collisions between RPAS and manned aircraft. These are informed by abundant aircraft birdstrike data.

RPAS collisions with high capacity air transport aircraft can be expected to lead to an engine ingestion in about eight per cent of strikes. The proportion of ingestions expected to cause engine damage and engine shutdown will be higher than for bird ingestion (20 per cent of ingestions).

RPAS have the potential to damage a general aviation aircraft's flight surfaces (wings and tail), which could result in a loss of control. Furthermore, a collision with a general aviation aircraft's windscreen poses a high risk of penetration.

The operation of remotely piloted aircraft is an emerging risk to transport safety that requires close monitoring as the popularity of these aircraft continues to grow rapidly.

A safety analysis of remotely piloted aircraft systems 2012 to 2016: A rapid growth and safety implications for traditional aviation (AR-2017-016) is available on the ATSB website at www.atsb.gov.au

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Fostering safety awareness, knowledge and action

The ATSB conducts activities relating to its responsibilities for increasing awareness of safety issues and complying with international safety obligations. This section describes the ATSB's performance against the deliverables set out on page 116 of the Portfolio Budget Statements 2016–17.

Deliverable

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

Regional cooperation

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

Many countries do not have a well-developed capability to investigate accidents and serious incidents. Australia will pursue opportunities to provide support in the Asia–Pacific region, including taking a leading role in the ICAO Asia Pacific Accident Investigation Group (APAC AIG) and the Marine Accident Investigators Forum in Asia (MAIFA).

Indonesia

The ATSB and the Indonesian National Transportation Safety Committee (NTSC) collaborated on a range of ITSAP activities in 2016–17, including cooperation between the ATSB and NTSC transport recorder laboratories. Activities included a 'train-the-trainer' project to develop an NTSC Investigation Analysis course that was successfully delivered to NTSC aviation, rail and marine investigators. This is a significant achievement, as very few investigation agencies worldwide have developed and delivered this type of training. An NTSC aviation investigator, a human factors investigator, and a recorder specialist visited the ATSB for on-the-job training and professional development. The ATSB also delivered a rail safety investigation training course to the NTSC and other Indonesian rail industry participants.

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Papua New Guinea

Under the Papua New Guinea Memorandum of Understanding on Cooperation in the Transport Sector, the ATSB has an ongoing program of cooperation and capability building with the Papua New Guinea Accident Investigation Commission (AIC). An ATSB Senior Transport Safety Investigator (STSI) is deployed full-time to the AIC in Port Moresby to assist Papua New Guinea in developing the capability to meet the international requirements for aviation safety investigation. A key focus of the ATSB–AIC program is the development of a Papua New Guinea Diploma of Transport Safety Investigation that will form the framework for AIC investigator training. Through this program, AIC investigators have received training in human factors, flight recorders and other aspects of accident investigation.

Other regional engagement activities

The ATSB continued to make its expertise and resources widely available in support of regional transport safety. Representatives from Finland, New Zealand, China, Vietnam, Korea and Kiribati visited the ATSB for discussions related to transport safety. In addition, participants from Taiwan, Bangladesh, Finland, Vietnam, Indonesia, Papua New Guinea, Singapore, Saudi Arabia and New Zealand attended ATSB investigator training courses. The ATSB also delivered an investigator training course to our counterpart agency in Vietnam. This year, the ATSB hosted the 19th MAIFA attracting participation from Cambodia, the People's Republic of China, Hong Kong, Japan, the Republic of Korea, Malaysia, New Zealand, Singapore, Thailand and Vietnam.

Communication and education

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

In 2016–17, we continued to highlight, for the benefit of industry and the travelling public, emerging safety issues and trends using a range of communication channels and activities.

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SafetyWatch

In 2016–17, we continued to promote our SafetyWatch initiative. SafetyWatch highlights the areas of broad safety concern identified from our investigations and the occurrence data reported to us by industry.

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

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

Icon for social media

Social media

During 2016–17, we made extensive use of our social media platforms to engage with the transport industry, the media and the travelling public.

Since launching the ATSB's Facebook page in July 2015, the ATSB has attracted around 11,500 followers to this platform. In 2016–17 this resulted in almost 140,000 referred visitors to the ATSB website.

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

By the end of June 2017, the ATSB's Twitter followers had increased to almost 7,000 people. These include journalists, members of the public and transport industry specialists.

In 2016–17, we also increased our engagement with audiences through videos, hosted on our website and the ATSB's YouTube channel.

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Media

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

Major press conferences throughout the year include those held in relation to the search for MH370, and conferences held onsite for the following accident investigations:

  • Collision with terrain involving Cessna 441, VH-XMJ near Renmark Airport, South Australia on 30 May 2017 (AO-2017-057)
  • Collision with terrain involving B200 King Air, VH-ZCR at Essendon Airport, Victoria on 21 February 2017 (AO-2017-024)
  • Collision with terrain involving SOCATA TB-10 Tobago, VH-YTM, near Mount Gambier Airport, South Australia on 28 June 2017 (AO-2017-069).

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

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Website

The ATSB website (www.atsb.gov.au) continues to be our principal communication channel. In 2016–17, the ATSB website received 2,664,309 page views. This equated to 884,376 sessions, which is an increase of 9.3 per cent from the previous financial year.

The launch of the ATSB Facebook page has been particularly effective in referring users to the ATSB website. In 2016–17, Facebook resulted in close to 200,000 views on the ATSB website. This made Facebook the number one referral site for the second year in a row.

Going digital

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

In 2016–17, we continued to release all of our reports in html format (along with current pdf and rich text formats).

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

avdata

Online aviation database

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

In 2016–17, the National Aviation Occurrence Database had 6,361 page views.

Industry engagement

The ATSB continued its strong record of engagement with industry in 2016–17 through: participation in consultative forums with industry and other safety agencies; representation at conferences and events; bilateral engagement with operators, associations and other stakeholders; and active involvement in safety education forums.

This included participation in the following events:

  • Regional Aviation Association of Australia Convention
  • Airservices Australia Waypoint
  • Australian Women Pilots' Association Conference
  • Aerial Application Association of Australia Convention
  • Australian Airports Association National Conference
  • Australian Aviation Psychology Association Symposium
  • Recreational Aviation Australia Safety Summit
  • Transport Safety and Security Forum (Indonesia)
  • Australia–Indonesia Transport Sector Forum (Indonesia)
  • International Society of Air Safety Investigators (Iceland)
  • Marine Accident Investors Forum in Asia (Canberra)
  • Royal Federation of Aero Clubs of Australia
  • La Trobe Valley Aero Club
  • Aviation Law Association of Australia and New Zealand (New Zealand)
  • Directorate of Defence Aviation and Airforce Safety
  • Royal Australian Air Force
  • Australian Army 6th Aviation Regiment

The ATSB also welcomed a number of visitors to its office in Canberra throughout the year, providing an opportunity for representatives from the aviation, marine and rail sectors to meet key staff and tour the laboratory facilities.

Financial performance

This section should be read in conjunction with the ATSB's audited financial statements for 2016–17 that appear in section 7 of this report.

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

During the year, ATSB's operating environment continued to be influenced by the:

  • continuing search for the missing MH370
  • ongoing requirements to position the ATSB to sustainably operate within available resources.

The ATSB recorded a deficit of $6.5 million for 2016–17, compared to a deficit of $2.5 million in 2015–16. Excluding depreciation and amortisation, the ATSB realised an underlying deficit of $5.7 million which compares to a $1.6 million deficit in 2015–16.

ATSB's approved operating loss for 2016–17 after accounting for depreciation and amortisation, was $23.8 million compared to an actual operating loss of $6.5 million, mainly due to the timing differences between revenue received and related expenditure in relation to the search for MH370.

During 2016–17, the ATSB received additional appropriation revenue to assist the agency with the implementation of its budget sustainability strategy, and also additional funding in relation to the search for MH370.

During the year, the ATSB has recognised additional $19 million in contributions from other countries in relation to the search for the MH370, with the majority of the additional contributions utilised in 2016–17.

The ATSB's new capital requirements are detailed in its Departmental Capital Budget published in the Portfolio Budget Statements 2016–17. Over time, the ATSB's estimated capital injections fall short of the deficits associated with the non-funding of depreciation and amortisation. Without adequate capital injections by Government, this presents a challenge to the ATSB in maintaining its underlying equity and asset capability going forward.

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

Table 4: Summary of financial performance and position

2016–17 $M

2015–16 $M

Revenue from Government

22.8

68.2

Other revenue

22.5

39.6

Total income

45.3

107.8

Employee expenses

16.5

15.4

Supplier expenses

34.5

94.0

Depreciation and amortisation

0.8

0.9

Total expenses

51.8

110.3

Operating surplus/(deficit)

(6.5)

(2.5)

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The search for Malaysia Airlines Flight 370

Background

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

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

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

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

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

Under agreement between Australia and Malaysia, a surface search of probable impact areas along the arc was carried out from 18 March to 28 April 2014, coordinated by the Australian Maritime Safety Authority. This included an underwater search for the flight recorders using a towed pinger locator, sonar buoys and an autonomous underwater vehicle to search the ocean floor, in the northern section of the search area, which continued until 28 May 2014.

On completion of the surface search, the ATSB became responsible for refining the search area and leading an expanded underwater search. The Search Strategy Working Group (SSWG) came together to define the most probable position of the aircraft at the time of the last satellite communication. The SSWG included specialists from the following organisations:

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

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

Continuing analysis to define the most prospective underwater search area is detailed in the following technical reports:

  • In June 2014, the ATSB published MH370—Definition of Underwater Search Areas, describing the methods and means used to identify a priority search area of 60,000 square kilometres. In August 2014, the ATSB published an updated version of the report, which included additional explanatory material.
  • In October 2014, the ATSB published MH370—Flight Path Analysis Update to supplement the previously released report, with refinements to the analysis indicating the search should be prioritised further south within the wide area search area.
  • In December 2015, the ATSB published the update MH370—Definition of Underwater Search Areas, which describes the results of the Australian Defence Science and Technology Group (DST Group, formerly DSTO) comprehensive analysis of available data. DST Group produced a book titled Bayesian methods in the search for MH370 detailing the entire analysis.

Underwater search operations led by the ATSB have involved a number of vessels and types of search equipment.

Initially the sea floor in the search area was mapped by the Fugro vessel, Fugro Equator, and the People's Republic of China vessel, Zhu Kezhen, using hull-mounted multibeam sonar systems. This work was necessary to ensure the safe operation of the sonar search systems in close proximity to the seafloor in an area of the Indian Ocean which has never been mapped in detail before.

The Malaysian-contracted vessel GO Phoenix commenced the high-resolution underwater search late in 2014, equipped with the 6,000 m rated SLH ProSAS-60 synthetic aperture sonar deep tow vehicle and mission crew provided by Phoenix International and Hydrospheric Solutions, Inc. GO Phoenix was soon joined in the search by the Fugro vessel, Fugro Discovery, equipped with a 6,000 m rated EdgeTech deep tow vehicle.

By January 2015, Fugro Equator had completed initial seafloor mapping activities and also mobilised an EdgeTech deep tow vehicle to join the underwater search operation. The deep tow search vehicles were fitted with instruments including synthetic aperture or side scan sonar and multibeam echo sounders, and were towed at an altitude of between 100 m and 200 m above the sea floor on a cable up to 9 km behind the vessel.

In the summer months of 2015 and 2016, Fugro vessels Fugro Supporter and Havila Harmony joined the underwater search with a Hugin 4500 autonomous underwater vehicle (AUV). An AUV is a free-swimming vehicle with a battery-powered propulsion system and sonar instruments similar to the deep tow vehicles. The AUV was highly manoeuvrable and therefore capable of surveying the difficult terrain in some parts of the search area more effectively than the deep tow vehicles.

In 2016, the People's Republic of China vessel Dong Hai Jiu 101 joined the underwater search equipped with the SLH ProSAS-60 synthetic aperture sonar deep tow vehicle and mission crew once again provided by Phoenix International and Hydrospheric Solutions, Inc.

Operational challenges

By 30 June 2016, more than 110,000 square kilometres of seafloor in the southern Indian Ocean had been searched. Rough seas and strong winds continued to impact the search operation during the winter months, with sea states at times preventing the safe launch and recovery of the search vehicles from Fugro Discovery, Fugro Equator and Dong Hai Jiu 101. Poor weather conditions also contributed to Fugro Discovery sustaining some damage to a propeller shaft bearing and the tow cable, resulting in delays to search operations as vessel repairs were undertaken in the first two weeks of July 2016.

On 13 July 2016, Fugro Equator recorded a combined wave/swell height of 24.03 m (trough to peak), one of the largest waves ever recorded by shipborne sensors. This occurred in a 12 hour period in which four other waves over 20 m were recorded. The safety of the search vessel crews, always the first priority, meant serious consideration was given to suspending search operations over the 2016 winter months.

Winter weather conditions continued to impact search operations into August 2016, precluding the safe launch and recovery of the very large SLH ProSAS-60 vehicle from Dong Hai Jiu 101. Search operations on Dong Hai Jiu 101 were suspended, with the vessel remaining at anchor off Fremantle until weather conditions improved.

Figure 1: Winter weather conditions experienced by Dong Hai Jiu 101 in 2016

Winter weather conditions experienced by Dong Hai Jiu 101 in 2016

Source: Phoenix International/Hydrospheric Solutions, Inc.

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Debris analysis

During 2016, the ATSB continued to analyse a number of the items of aircraft debris which had been recovered from the shorelines of western Indian Ocean nations. In July a large section of wing flap, found on Pemba Island off the coast of Tanzania in June, arrived in Australia at the ATSB laboratories for identification and analysis. ATSB report Debris examination–update No. 3, published on 15 September 2016, confirmed that the section of wing flap was from the Malaysia Airlines aircraft operating as Flight 370 (MH370) and registered 9M-MRO.

A further two debris examination reports were issued by the ATSB in 2016–17:

  • Debris examinationupdate No. 4, published on 22 September 2016, which reported findings of preliminary examinations of two items of fibreglass-honeycomb composite debris recovered near Sainte Luce, Madagascar.
  • Debris examinationupdate No. 5, published on 7 October 2016, identified an item of composite debris recovered on the island of Mauritius in May 2016 as the trailing edge section MH370's left outboard wing flap.

Figure 2: Investigators examine a piece of aircraft debris, 2 July 2016

Investigators examine a piece of aircraft debris, 2 July 2016

Source: ATSB

The ATSB continued to assist the Commonwealth Scientific and Industrial Research Organisation (CSIRO) in undertaking a further study to model the drift of MH370 debris, using physical replicas of key items of debris which had been identified as originating from MH370. This work was commissioned by the ATSB in April 2016.

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First Principles Review

On 2 November 2016, the Minister for Infrastructure and Transport and the ATSB Chief Commissioner released the MH370Search and debris examination update report as the latest update to the MH370 search area definition described in previous ATSB reports. The report comprised of a further analysis of satellite data by DST Group, additional end-of-flight simulations, a summary of ATSB's analysis of the right outboard wing flap and preliminary results from CSIRO's debris drift modelling. The report detailed new information relating to the end-of-flight for MH370, including that the aircraft was in a steep and increasing rate of descent, and that the flap was most likely in the retracted position at the time it separated from the wing.

The Minister and Chief Commissioner also welcomed Australian and international members of the SSWG and other experts and advisors to the ATSB to participate in a First Principles Review. Convened from 2–4 November 2016, meeting participants reviewed all the available data and analysis associated with the search to that time. Representatives attended from all of the organisations participating in the SSWG, including Australia's DST Group, Boeing, Thales, Inmarsat, the National Transportation Safety Board of the US, the Air Accidents Investigation Branch of the UK and the Department of Civil Aviation, Malaysia. Representatives also attended from CSIRO, Geoscience Australia, Curtin University, Malaysia Airlines and the People's Republic of China.

Participants consisted of experts in data processing, satellite communications, accident investigation, aircraft performance, flight operations, sonar data, acoustic data and oceanography. The purpose of the meeting was to reassess and validate existing evidence and to identify any new analysis that may assist in identifying the location of the missing aircraft.

The ATSB published a report detailing the proceedings and outcomes of the First Principles Review meeting on 20 December 2016. The report concluded that the updated independent analysis of the satellite data and the drift analysis consistently identified the most likely impact location of MH370 as being close to the 7th arc (within ~25 NM) and bounded by latitudes of approximately 33 degrees to 36 degrees.

There was a high degree of confidence that the previously identified underwater area searched to that time did not contain the missing aircraft. Given the elimination of this area, the experts at the First Principles Review identified an area of approximately 25,000 square kilometres as the area with the highest probability of containing the wreckage of the aircraft. The experts concluded that, if this area were to be searched, prospective areas for locating the aircraft wreckage, based on all the analysis to date, would be exhausted.

Concurrent with the release of the ATSB First Principles Review report, CSIRO also released its The search for MH370 and ocean surface drift detailing the results of drift modelling of aircraft debris in the southern Indian Ocean.

The final stages

On 22 July 2016, senior Ministers from Malaysia, Australia and the People's Republic of China met to discuss the status of the search. Ministers agreed that should the aircraft not be found, the search would be suspended on completion of the 120,000 square kilometre search area agreed in April 2015.

With less than 10,000 square kilometres of search area remaining, vessels began to progressively depart the search. Fugro Discovery departed the search in August 2016 to undertake mandatory scheduled maintenance.

Search operations moved from deep tow operations to AUV and Remotely Operated Vehicle (ROV) operations with the onset of better weather in October 2016. The AUV and ROV operations were planned to increase overall coverage of the highest probability search area and reacquire a range of previously identified sonar contacts.

Table 5: Sonar contacts identified during the underwater search

Classification of sonar contacts

Sonar contacts identified

Classification 3 sonar contacts: of some interest as they stand out from their surroundings but have low probability of being significant to the search

More than 600

Classification 2 sonar contacts: of more interest but are still unlikely to be significant to the search

More than 40

Classification 1 sonar contacts: of high interest and warrant immediate further investigation

2 (a rock field and an old wooden shipwreck)

Fugro Equator demobilised the EdgeTech deep tow search system and mobilised the Hugin 4500 AUV to perform sonar data gap infill operations and undertake some sonar contact investigations.

The Remora III ROV was mobilised on Dong Hai Jiu 101 and used to undertake a number of sonar contact investigations to positively identify or discount sonar contacts as MH370-related. Dong Hai Jiu 101 departed the search in early December 2016 after undertaking video investigations of 38 contacts of interest in the search area.

In all, 82 sonar contacts were investigated using the deep tow vehicles, the AUV and ROV. All the sonar contacts investigated during the search were identified as geology, with the exception of a steel cable, oil barrel and four shipwrecks.

Figure 3: ROV images of verified man-made findings

ROV images of verified man-made findings

Source: Phoenix International/ATSB

On 17 January 2017, Fugro Equator, as the longest serving vessel in the search, completed AUV operations and departed the search area. At this time the Tripartite governments of Malaysia, Australia and the People's Republic of China issued a Joint Communiqué announcing the formal suspension of underwater search operations with the departure of the last remaining vessel from the search area.

On the arrival of Fugro Equator back in Australia for demobilisation, Australian and Malaysian Ministers, accompanied by a representative of the People's Republic of China, held a Ministerial press conference alongside Fugro Equator on 23 January 2017. The vessel crew were thanked for their tireless efforts over the previous three years, working in some of the most remote and inhospitable ocean conditions in the world.

Malaysia also announced the creation of a response team within its Department of Civil Aviation to continue analysing information to assist in the search for MH370.

Figure 4: Ministerial visit on board Fugro Equator, January 2017

Ministerial visit on board Fugro Equator, January 2017

Source: ATSB

During the underwater search, the 120,000 square kilometre search area was searched to a high degree of confidence, 278,000 square kilometres of seafloor along the 7th arc was mapped, and 432,000 square kilometres of seafloor was mapped during vessel transit between port and the search area.

Search vessels completed 59 vessel swings using a range of search equipment. A swing typically consists of about 40 days at sea, as a journey from port to the search area, time spent on the search, and return journey to port.

Table 6: Underwater search vessel swings

Vessel

Multi-beam

Deep tow

AUV

ROV

Total

Fugro Equator*

5

15

2

0

22

Zhu Kezhen

4

0

0

0

4

GO Phoenix

0

8

0

0

8

Fugro Discovery

0

16

0

0

16

Fugro Supporter*

0

0

3

0

3

Havila Harmony

0

0

2

0

2

Dong Hai Jiu 101

0

3

0

1

4

9

42

7

1

59

* Fugro Equator and Fugro Supporter also progressively acquired bathymetric survey data during deep tow operations as required.

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Continuing analysis

With the suspension of search operations, the ATSB has continued with search area analysis activities, including a further review of sonar data and analysis of available satellite imagery.

Wednesday 8 March 2017 marked the third anniversary of the disappearance of MH370. The ATSB Chief Commissioner and members of the ATSB MH370 team (including personnel from Defence, Geoscience Australia and DST Group) travelled to Brisbane to join the Australian families of those on board the missing aircraft at a national memorial service. The service was a moving, solemn and appropriate tribute to the seven Australian citizens and residents, as well as the other 232 passengers and crew, on board MH370. Former Deputy Prime Minister Warren Truss attended, and Minister for Infrastructure and Transport, Darren Chester, and Sir Angus Houston were among those who addressed the congregation.

On 21 April 2017, CSIRO released The search for MH370 and ocean surface driftPart II as an addendum to their previous drift modelling report released in December 2016. The report details the results of field tests conducted with a second-hand flaperon modified to be a precise facsimile of the flaperon from MH370, which washed ashore on La Réunion Island on 29 July 2015. The results largely confirm numerical predictions for relative rates and directions of drift in varying conditions of wind and waves which further refine the CSIRO drift model for MH370 debris. The results did not change the earlier estimate of the most probable location of the aircraft. The results did increase confidence in the estimated location of the search area identified and recommended in the First Principles Review report, near 35 degrees.

The final report on the Operational Search for MH370 details all relevant facets of Australia's involvement in the search for MH370 from 8 March 2014, including the surface search, the initial underwater search for the flight recorder underwater locator beacons and the underwater search. The report captures all the analysis which led to decisions in relation to the search area, the method used for the underwater search and the results of the search. It also discusses the management of the operational search program, including the significant risks associated with conducting the search in a very remote area with often adverse weather in ultra-deep water with challenging seafloor terrain. The report was released in October 2017.

Staff in the operational search team at the ATSB are working to finalise all facets of the program, including the archival and audit of program documentation, managing media and public enquiries, program finances and contractual arrangements, and continuing engagement with the Malaysian Annex 13 investigation team.

From 1 July 2017, the ATSB continued to liaise in a 'business-as-usual' manner with the Malaysian Annex 13 investigation team, assessing and responding to any requests for assistance with the analysis of debris, which may well wash ashore in any of the countries on the Indian Ocean rim in the years to come.

Figure 5: MH370 Tripartite Ministers' Joint Communique, January 2017

MH370 Tripartite Ministers' Joint Communique, January 2017

Source: Joint Agency Coordination Centre/Geoscience Australia