Management and accountability

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The Commission

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

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

The Commission operates within the corporate governance framework of the ATSB Commission Governance Manual. The manual sets out the Commission’s legislative requirements, parliamentary and ministerial accountability, membership and functions, administrative policies and procedures, and reporting obligations.

The Commission meets face-to-face at least four times a year and manages ATSB business through regular teleconferences and electronic communications in accordance with its obligations under the TSI Act and its agreed policies.

All Commissioners participated in three Commission meetings during 2016–17. The Commissioners also attended the annual joint Papua New Guinea Accident Investigation Commission and Australian Transport Safety Bureau Commissioners’ Meeting in April 2017.

Commissioner Chris Manning attended the May 2017 Senate Estimates hearing before the Rural and Regional Affairs and Transport Legislation Committee. Commissioner Manning attended in his capacity as the Commission spokesperson for the ATSB’s reopened investigation into the ditching of Israel Aircraft Westwind 1124A aircraft, VH-NGA, 5 km SW of Norfolk Island Airport on 18 November 2009 (AO-2009-072).

Executive management

The ATSB Executive meets weekly to discuss strategic management issues and priorities. Prior to the organisational restructure taking effect in June 2017, the ATSB Executive consisted of the Chief Commissioner, the General Managers of Aviation Safety Investigations, Surface Safety Investigations and Strategic Capability, and the Program Director, Operational Search for MH370.

Following the organisational restructure, the ATSB Executive consists of the Chief Commissioner, the Executive Director Transport Safety, the Chief Operating Officer and the Program Director, Operational Search for MH370.

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Audit Committee

The Audit Committee provides independent assurance and advice to the Chief Commissioner on the ATSB’s risk management, internal controls, financial statements and legislative compliance. The Audit Committee consists of an independent chair, an independent member and an ATSB management nominee. The Committee’s quarterly meetings were held in September and December 2016, and March and June 2017.

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

  • the annual Internal Audit Program for 2016–17
  • the ATSB’s Risk Management, Fraud Control and Business Continuity Plans
  • the ATSB’s Financial Statement preparations
  • implementation of the Public Governance, Performance and Accountability Act 2013 (PGPA Act) and the associated Rule
  • the internal audit governance framework—including Audit Committee Charter, Internal Audit Charter and Internal Audit Strategic Plan 2014–17.

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

The audit program for 2016–17 focused on assuring the ATSB’s legislative compliance and performance against its core functions. The program included the following internal audits:

  • International Civil Aviation Organization audit to determine Australia’s compliance with international standards, recommended practices and guidance for aircraft accident investigation
  • internal audit of payroll
  • implementation of Public Governance, Performance and Accountability Act 2013 requirements for performance reporting
  • MH370 Program Closure Review.

Change Management advisory team

During 2016–17, a program of organisational change called the ‘Evolution Program’ was developed and implemented in the ATSB. The purpose of the Evolution Program was to improve the ATSB’s efficiency and effectiveness. The objectives included becoming more data driven and adopting a multi-disciplinary approach that broke down any entrenched barriers which may have been an inhibitor to broader organisational collaboration.

A Change Management team was established to define the process and expected outcomes. The team consisted of eight employees representing different areas of the organisation. The team met regularly throughout 2016–17, focussing on the following work streams:

  • the ATSB’s deliverables and key performance indicators
  • the ATSB’s organisational structure
  • resource allocation and workload tracking
  • data capability
  • safety communication and education
  • human resources framework.

Business planning and reporting

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

The ATSB Annual Plan 2016–17 gave priority to:

  • focused safety data recording, research and analysis
  • undertaking and completing investigations of transport accidents, serious incidents and other safety occurrences
  • maintaining our operational capabilities and readiness, including preparedness for a major accident
  • actively participating in transport safety reforms
  • fostering safety awareness, knowledge and action, including through the SafetyWatch priorities
  • maintaining stakeholder relationships (including regional and international engagement)
  • actioning key operational projects, including continuing the search for MH370.

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

Risk management

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

The ATSB is committed to a comprehensive, coordinated and systematic approach to the management of risk—directed towards supporting managers at all levels to anticipate and plan for risk, and to respond appropriately. For 2016–17, the ATSB concentrated its risk focus on the areas of service delivery, health and safety, security, financial/economic, compliance and reputation.

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

Business Continuity Plan

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

In 2016–17, the ATSB continued to review and test its operational risk management processes and responses, which mitigate the impact of non-routine business disruptions. The Audit Committee regularly reviews the ATSB’s business continuity operations.

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Fraud control

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

The ATSB’s fraud risk register is monitored to minimise the incidence of fraud. This process is assisted through the development, implementation and regular assessment of its fraud prevention, detection and response strategies.

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

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

There were no allegations, or instances, of fraud reported within the ATSB during 2016–17.

Ethical standards

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

  • highlighting the APS Values, Employment Principles and Code of Conduct in all selection criteria and recruitment processes for all ATSB positions
  • including briefing information on the APS Values, Employment Principles and Code of Conduct in induction packages and training sessions
  • promoting the APS Values, Employment Principles and Code of Conduct through individual performance management plans
  • ensuring employees are able to access information on ethical standards via the ATSB’s intranet and the Australian Public Service Commission’s (APSC) website
  • having Public Interest Disclosure policy and procedures in place
  • embedding the APS Values in the Corporate Plan
  • ensuring that the ATSB’s fraud control policy, allegations and investigations are dealt with in accordance with the Values and Code of Conduct, which confirms procedural fairness and natural justice.

Management of human resources

The ATSB recognises the essential contribution that its people make to achieving our purpose, and the importance of investing in staff capability. Over the past year, the Organisational Development team has invested significant time and effort into supporting the ATSB’s Evolution Program.

This year has presented the Organisational Development team with a unique opportunity to redefine the ATSB’s human resources and learning and development frameworks. The Organisational Development team worked closely with the Evolution Program’s leadership team, managers and staff across the ATSB to design new frameworks and implement a range of new initiatives, positioning the team to better manage, monitor and support our evolving workforce.

The work and activities undertaken by the Organisational Development team include:

  • completion of a comprehensive review of the ATSB’s learning and development framework
  • revitalisation and enhancements to the ATSB’s training material and resources
  • establishment of a new approach to managing performance and development opportunities
  • introduction of new workforce metrics to effectively monitor resourcing requirements and develop the skills and competencies necessary to function as a modern transport safety agency
  • proactive support and advice to managers and staff on employment matters, and ongoing commitment to ensure a safe and healthy workplace
  • championing the Evolution Program and the transition to a new organisational structure
  • creation of a bespoke ATSB leadership and cultural change program
  • greater awareness and improved recruitment processes targeting diversity groups
  • new partnerships with cross-portfolio agencies to increase development and inter-agency opportunities
  • building and maintaining close relationships with business partners to effectively manage day-to-day operational requirements.

Over this reporting period, there has been a particular focus on developing our people to address any workforce risks resulting from the Evolution Program and regularly analysing the agency’s ongoing capacity to maintain its primary objective, key functions and broader portfolio responsibilities.

Staffing profile

In accordance with our workforce planning projections, the ATSB’s staffing profile has remained relatively stable, from 102 at the end of June 2016 to 107 by the end of June 2017. The associated staff turnover rate was approximately 15 per cent. Table 21 displays the ATSB staff numbers, by classification, as of 30 June 2017.

Table 21: The ATSB’s staffing profile at 30 June 2017

Substantive classification

Gender x (full time)

Female (full time)

Female (part time)

Male (full time)

Male (part time)

Non- ongoing


Statutory Office Holders





Senior Executive Service Band 1



EL 2







EL 1





























This total is comprised of the following employment arrangements:

  • 101 staff (representing all non-SES employees) covered by the enterprise agreement
  • two SES employees covered by section 24(1) determinations, established in accordance with the ATSB’s SES remuneration policy
  • four Statutory Office Holders (representing the Commissioners) determined by the Remuneration Tribunal.

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

This total comprises 86 staff based in Canberra, ten based in Brisbane, five based in Adelaide, three based in Perth, one based in Sydney and one based overseas in Port Moresby.

Non-salary benefits provided to employees under the enterprise agreement include:

  • options for home-based work
  • ability to work part-time
  • flexible working arrangements
  • access to different leave types
  • influenza vaccinations
  • access to the Employee Assistance Program.

Indigenous employees

At 30 June 2017, the ATSB had one ongoing employee who identified as Indigenous. The ATSB participates in the portfolio-wide indigenous network run by the Department of Infrastructure and Regional Development.

Salary rates

Table 22 displays the salary rates supporting the above employment arrangements at 30 June 2017.

Table 22: The ATSB’s salary rates at 30 June 2017

Substantive classification

Lower ($)

Upper ($)

Statutory Office Holders

As determined by the Remuneration Tribunal




EL 2



EL 1












* Maximums include Transport Safety Investigator and respective supervisor’s salaries, representing a $1,953–$9,989 increase on standard APS6–EL2 rates.

Organisational culture

2016–17 presented new challenges for the ATSB with the development and implementation of the Evolution Program. The ATSB has refined its organisational hierarchy, enabling us to better focus on our organisational objectives and improve our efficiency and effectiveness.

This is the first time our managers and staff have embarked on a significant program of change since becoming an independent agency. Our enduring organisational culture, and underlying morale, has enabled our workforce to work collaboratively and maintain focus on achieving our objectives into the future.

When taking into account our agency’s wellbeing indicators, derived from the 2017 staff census results, it is pleasing to see that our staff remain positive in terms of their jobs, attachment to the purpose of the agency, feelings of personal accomplishment and workplace safety—as evidenced by these census results:

  • 88% of staff are proud to work in the ATSB
  • 75% of staff think the ATSB supports employees who are injured or become ill due to work
  • 79% of staff say that the ATSB is committed to creating a diverse workforce
  • 96% of staff are happy to go the ‘extra mile’ at work when required
  • 88% of staff believe we are committed to workplace safety
  • 84% of staff feel that people in the workgroup treat each other with respect
  • 88% of staff believe there is a strong culture of using data and evidence in our work
  • 92% of staff believe their immediate workgroup act in accordance with the APS values.

Conversely, we have a number of results (trends) that have been identified as new or ongoing challenges which have been captured and will be addressed in the year ahead. They are as follows:

  • I’m satisfied with the non-monetary employment conditions—down to 74% positive
  • I have choice in deciding how I do work—down to 64% positive
  • My immediate supervisor encourages me—down to 63% positive
  • My supervisor openly demonstrates commitment to performance management—down to 56%.

Training and development

During 2016–17, the ATSB completed a detailed learning and development review of all its internal and external training requirements, training resources and delivery methods. The ATSB Executive agreed to all 26 recommendations made. These recommendations provided a good opportunity to reform our approach to learning and development, including developing e-Learning solutions for suitable courses into the future. To date, the ATSB has successfully implemented five recommendations and work will continue on the successful implementation of the remaining recommendations.

In June 2017, the ATSB completed an approach to market to source a suitable partner, who is a Registered Training Organisation (RTO), to work closely with the ATSB to recommence the delivery of ATSB’s accredited Diploma of Transport Safety Investigation. The ATSB is pleased to be able to once again provide this formal qualification to our Transport Safety Investigators.

Throughout 2016–17, the ATSB refreshed and updated training resources, in tandem with the Evolution Program. As a result, new cross-modal training resources were developed and delivered to Transport Safety Investigators.

In 2016–17, the ATSB continued to provide training opportunities for a broad range of industry-based personnel, through its highly regarded Human Factors and Aircraft Accident Investigation Fundamentals courses. Other training delivered to ATSB personnel included:

  • Critical Incident Stress and Operational Management
  • Bloodborne Pathogens
  • Work Health Safety and On-site Safety
  • Cognitive Interviewing
  • Transport Safety Act 2003
  • Fraud Control
  • Records Management and Travel
  • ICT Security
  • Media Awareness
  • Workplace Harassment Contact Officer
  • Safety Investigation Quality System
  • Overview of Investigation Analysis and Safety Investigation Information Management System
  • Cross-modal (Rail, Marine and Aviation).

By recruiting personnel with workplace coaching qualifications, the ATSB has been able to establish and offer both formal and informal coaching development opportunities to managers and staff throughout the year.

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

  • it undertakes competitive, non-discriminatory procurements
  • it uses resources efficiently, effectively, economically and ethically
  • it makes all procurement decisions in an accountable and transparent manner.
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The ATSB engages consultants when it lacks specialist expertise, or when independent research, review or assessment is required. Consultants are typically engaged to:

  • investigate or diagnose a defined issue or problem
  • carry out defined reviews or evaluations
  • provide independent advice, information or creative solutions to assist in the ATSB’s decision making.

The ATSB policies on selection and engagement of consultants are in accordance with the CPRs. Before engaging consultants, the ATSB takes into account the skills and resources required for the task, the skills available internally and the cost effectiveness of engaging an external contractor.

During 2016–17, three new consultancy contracts were entered into involving total actual expenditure of $242,609. There were no ongoing consultancy contracts carried over from the 2015–16 year.

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

Australian National Audit Office access clauses

There were no contracts that did not provide for the Auditor-General to have access to the contractors’ premises during 2016–17.

Exempt contracts

No contracts were exempted, on public interest grounds, from publication with AusTender during 2016–17.

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Procurement initiatives to support small business

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

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

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Paragraph 11.1(a) of the Legal Services Directions 2017, issued by the Attorney General under the Judiciary Act 1903, requires chief executives of departments and agencies to ensure that legal services expenditure is appropriately recorded and monitored. Chief executives must also ensure that their agencies make records of their legal services expenditure for the previous financial year available by 30 October in the following financial year. The following amounts are exclusive of GST.

The ATSB’s expenditure on legal services for 2016–17 was $256,658.45, comprising:

  • $15,473.50 on external legal services
  • $241,184.95 on internal legal services.

External scrutiny and participation

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Coronial inquests

The ATSB was required to participate in one coronial inquest in 2016–17.

In-flight break-up involving PZL Mielec M18A Dromader aircraft, VH-TZJ, 37 km west of Ulladulla, New South Wales, 24 October 2013

On 13 March 2017, New South Wales Deputy State Coroner, Derek Lee, made findings following an inquest for an in-flight break-up involving PZL Mielec M18A Dromader aircraft, VH-TZJ, 37 km west of Ulladulla, New South Wales on 24 October 2013. The aircraft had been conducting a firebombing mission when, on approach to the target position, the left wings separated. The aircraft impacted the terrain and was destroyed, with the pilot being fatally injured.

The ATSB’s investigation found that the left wing separated because it had been weakened by a fatigue crack in the left wing lower attachment fitting. The fatigue crack originated at the attachment lugs. The pits formed stress concentrations that accelerated the initiation of fatigue cracks.

The ATSB also found that, although required to be removed by the aircraft manufacturer’s instructions, the corrosion pits were not completely removed during previous maintenance. During that maintenance, the wing fittings were inspected using an eddy current inspection method. This inspection method was not approved for that particular inspection and may not have been effective at detecting the crack.

Data from a series of previous flights indicated that the manner in which the aircraft was flown during its life probably accelerated the initiation and growth of the fatigue crack.

Finally, the ATSB also found a number of other factors which, although they did not contribute to the accident, had potential to reduce the safety of operation of PZL M18 and other aircraft. These included the incorrect calculation of the flight time of M18 aircraft and a lack of robust requirements for the approval of non-destructive inspection procedures.

The ATSB released its findings on 15 February 2016. The inquest was held 27 February to 1 March 2017 and 6 March 2017 at the New South Wales State Coroner’s Court in Glebe. The Coroner agreed with the ATSB’s findings.

The ATSB’s investigation report (AO-2013-187) is available on the ATSB website at

Other coronial matters

Inquest into the disappearance and suspected death of Cesar Llanto and inquest into the death of Hector Collado

On 31 May 2017, New South Wales Deputy State Coroner, Sharon Freund, made findings in relation to the suspected death of Cesar Llanto and the death of Hector Collado. The Deputy State Coroner found that Cesar Llanto died on 30 August 2012 as a result of foul play, namely, that Mr Llanto was either thrown overboard or killed on the MV Sage Sagittarius and his body disposed of at a later time, by a person or persons unknown. The Coroner made an open finding in relation to the cause of death.

The Deputy State Coroner found that Hector Collado died on 14 September 2012 in Newcastle Harbour aboard the MV Sage Sagittarius. The cause of his death was multiple injuries which the Coroner was satisfied he sustained as a result of being struck over the head by some kind of weapon or instrument by a person or persons unknown and then he was either thrown over the handrail outside the storeroom on the second deck or fell over the handrail to his death.

The ATSB was notified in both cases but did not investigate due to the circumstances indicating the deaths were the result of deliberate actions. As it is not a function of the ATSB to apportion blame or provide the means to determine liability, the ATSB primarily investigates accidents involving transport vehicles.

The Coroner had evidence that audio was missing from the vessel’s Voyage Data Recorder (VDR) on the critical dates. The evidence concerning the missing audio precedes a recommendation by the Coroner that the New South Wales Police Force, the Australian Federal Police, the Australian Maritime Safety Authority and the Australian Transport Safety Bureau give consideration to establishing a standing group for investigations of deaths or suspicious deaths on board, or disappearance from, an international vessel in or bound for Australian waters. Recommendations included making the group responsible for providing all available expertise and assistance to ensure the proper downloading, seizure and storage of any VDR system on board the vessel.

The ATSB is liaising with the other authorities in response to the Coroners’ recommendations. In formulating a response, the ATSB will need to take into account that it must avoid apportioning blame or providing the means to determine liability.

In-flight break-up involving de Havilland DH82A Tiger Moth, VH-TSG 300 m east of South Stradbroke Island, Queensland, 16 December 2013

On 24 November 2016, South Eastern Queensland Coroner, James McDougall, made findings without an inquest into an accident involving a de Havilland DH82A (Tiger Moth) aircraft, registered VH-TSG, which took off from the operator’s airstrip at Pimpama, Queensland, with a pilot and passenger on board. The purpose of the flight was to conduct a commercial joy flight in the Gold Coast area. At about 1224, one minute after the pilot commenced aerobatics, the left wings failed and the aircraft descended steeply; impacting the water about 300 m from the eastern shoreline of South Stradbroke Island. The aircraft was destroyed and the two occupants were fatally injured.

The ATSB found that both of the aircraft’s fuselage lateral tie rods, which assist in transferring flight loads through the fuselage, had fractured. The location of the fracture coincided with areas of pre-existing fatigue cracking in the threaded sections of the rods, near the join with the left wing. The tie rods fractured during an aerobatic manoeuvre, resulting in the left lower wing separating from the aircraft and subsequent in-flight break-up. The ATSB also found that the tie rods were aftermarket parts manufactured under an Australian Parts Manufacturer Approval (APMA). In this respect, safety issues were identified in areas of the tie rods’ design and manufacture, as well as in the supporting regulatory approval processes. Safety issues were also identified in the maintenance and operation of the aircraft.

The ATSB consulted with the Type Design Organisation, regulators and investigation authorities from Australia, New Zealand and the United Kingdom about the failure of the APMA tie rods, which occurred well before the published retirement life for Tiger Moth tie rods. In response, the United Kingdom Civil Aviation Authority issued an airworthiness directive on 21 March 2014 that mandated the removal from service of all tie rods produced by the same Australian manufacturer. The airworthiness directive was subsequently also mandated by the Australian Civil Aviation Safety Authority and the New Zealand Civil Aviation Authority. Significant additional safety action is proposed by the Type Design Organisation to further enhance the safety of all Tiger Moth operations. In addition, the ATSB issued a safety recommendation to CASA to take action to provide assurance that over 1,000 other parts approved for APMA at about the same time as the tie rods were appropriately considered before approval.

The ATSB released its findings on 21 January 2016. The Coroner agreed with the ATSB’s findings.

The ATSB’s investigation report (AO-2013-226) is available on the ATSB website at

Figure 28: Main wreckage from in-flight break-up involving PZL Mielec M18A Dromader aircraft (AO-2013-187)

Main wreckage from in-flight break-up involving PZL Mielec M18A Dromader aircraft

Source: ATSB

Figure 29: Left outboard wing, looking from the wingtip inboard and showing the lower surface of the wing from in‑flight break-up involving PZL Mielec M18A Dromader aircraft (AO-2013-187)

Left outboard wing, looking from the wingtip inboard and showing the lower surface of the wing from in‑flight break-up

Source: ATSB

Figure 30: VH-TSG after recovery: In flight break-up involving de Havilland DH82A Tiger Moth (AO-2013-226)

VH-TSG after recovery

Source: ATSB