The ATSB will release a final report at the conclusion of an investigation, detailing contributing factors, safety issues and other findings. However, at any time during the course of an investigation, should we uncover safety critical information we will immediately share that with relevant parties so they can take appropriate safety action.
Depending on the complexity of the occurrence and the scope of the investigation, the ATSB may also publish preliminary and interim reports.
Preliminary reports detail factual information determined in an investigation’s initial evidence collection phase and areas of ongoing investigation. They are typically released 1–4 months after the initial occurrence.
Interim reports detail more extensive factual information and outline areas of ongoing investigation.
During the course of an investigation, the ATSB also provides brief factual updates on an investigation's progress on our website.
Either in conjunction with a report release or at any time during an investigation, the ATSB may also issue a safety advisory notice to relevant organisations and industry sectors to highlight a safety issue or concern and advising that relevant parties take safety action where appropriate.
Final report structure
ATSB occurrence investigation final reports are organised with regard to international standards or instruments, as applicable, and with ATSB procedures and guidelines. Reports normally contain the following sections:
- Investigation summary—summarises the occurrence (or other transport safety matter), the investigations findings, any safety action taken as a result, and highlights broader safety messages.
- The occurrence—describes the sequence of events related to the occurrence and, if relevant, the consequences in terms of injuries and damage.
- Context—details the evidence collected during the investigation that is necessary to help the reader understand the occurrence and safety analysis, or the broader safety issues for research purposes.
- Safety analysis—outlines how the evidence justifies the investigation findings.
- Findings—the contributing factors, other factors that increased risk and other findings identified during the investigation and discussed in the safety analysis.
- Safety issues and actions—a summary of the safety issues identified during the investigation and details of what safety action has been taken, or is planned to be taken, by relevant parties to address those issues.
- Appendices—additional information that supports the report, for example, specialist reports on materials failure or flight data analysis.
Reports must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner.
Naming organisations in reports
ATSB policy provides for identifying most organisations in its transport safety investigations. Most organisations directly involved in any aviation occurrence investigated by the ATSB are identified in the report and on the investigation web page.
The policy ensures the ATSB’s compliance with the International Civil Aviation Organization’s recommended practices. It also ensures that the ATSB has a consistent and transparent approach across all of its aviation, rail and marine safety investigations.
Operators and other organisations can be assured that it is not a function of the ATSB to apportion blame or determine liability. Including the name of the organisation does not imply any adverse inferences.
Which organisations are identified
For aviation, all operators and regulators are identified.
For marine, all ship owners, ship management companies and the regulator are identified.
For rail, rail transport operators (rail infrastructure managers and/or rolling stock operators) and regulators are identified.
Other large organisations that contributed substantively to the occurrence will also be mentioned. The exception to the above policy will be where the operator is an individual or an individual’s name is the company name. Consistent with the Transport Safety Investigation Act 2003, the ATSB does not name individuals in its final reports.
Are there any exceptions?
If an operator or organisation had a passive or third-party involvement in an occurrence, the ATSB will not name that operator in the investigation report or published information.
Operators and other organisations will not be named in investigation report titles.
This policy applies to safety occurrences investigated by the ATSB from 1 July 2017. Any incident or accident that occurred before 1 July 2017 was treated under the previous policy.
How will an organisation know if they’re named?
The ATSB provides advance copies of its investigation reports to all organisations involved in a transport safety occurrence. This ensures organisations are aware of, and have the opportunity to provide feedback on, the report’s contents before it is made public.
Gender-neutral language in ATSB reports
All ATSB reports are de-identified. On the basis that gender‑specific language can lead to the identification of individuals, in 2020 the ATSB Commission adopted a policy of using gender‑neutral language in ATSB investigation reports.
In the report writing process, care is taken to ensure context and meaning are not lost.