Sections 25A of the TSI Act requires a person, association or agency to provide a written response to a Safety Recommendation contained in a report released under section 25 of the TSI Act(Opens in a new tab/window). The response is required within 90 days of the report being published. Responses to recommendations are published on the ATSB website.

Failure to respond may attract a penalty of up to 30 penalty points ($3,300 for a natural person and $16,500 for an incorporated organisation), and advice of any such failure to respond will be published on the ATSB website.

Policy

Responses to Safety Recommendations are to be provided within the timeframe (within 90 days of the report being published) as required by the TSI Act.

Where responses are not received, a decision about appropriate enforcement action is taken. Choice of an appropriate action is based on a graduated response that focuses on the primary objective to achieve an appropriate safety outcome, including to:

• continue to engage with the responsible person, or class of responsible persons, to ensure compliance; or if necessary
• refer the apparent breach to the Australian Federal Police (AFP) for investigation, with the potential for a brief of evidence to be provided by the AFP to the Commonwealth Director of Public Prosecutions (CDPP) to assess for possible prosecution action.

The ATSB's policy is that the option of continued engagement is used where the apparent breach does not meet the criteria for referring it to the AFP for investigation. The matter must be serious for a referral.

Criteria for referral

Where there is an apparent breach of section 25A of the TSI Act it is likely that it would only be considered serious if:
a) the person or organisation was aware of their obligations to respond, or should have in the circumstances been aware of their reporting obligations, and there is evidence to indicate that the person or organisation:

i.    deliberately decided not to respond in accordance with their obligations; or
ii.    was reckless in their failure to respond; and

b) the matter or matters that required a response:

i.    have the potential for serious safety consequences if not addressed; or
ii.    have the potential for less serious safety consequences but there is no other means to ensure that the person or organisation explains to the industry and the public how the matter or matters are being addressed; and

c) an investigation by the AFP, with potential prosecution by the CDPP, is thought necessary to:

i.    obtain compliance from the person now and in the future; or
ii.    deter other persons or organisations from failing to respond.

ATSB supplements

July - August

• Turning safety issues into action
• Kokoda crash prompts major safety improvements
• Managing Partial Power-Loss
• Pre-flight: Check your electrical power supply
• Pilots urged: 'stay focused around powerlines'
• Report confirms Qantas A380 engine failure event sequence
• Fact sheet for General Aviation Pilots
• Close flying highlighted in ATSB bulletin
• Bushfire fighting now safer
• Turbulences catches pilot off-guard
• Repcon briefs
• Download ATSB supplement (July-August 2011) [
  PDF: 918KB (894 KB)
  ]

May - June

• Talking with industry to improve safety
• Check Robinson R44 helicopter hydraulic-boost systems: ATSB urges operators
• Poor procedures top aviation safety issues
• General aviation has most fatalities
• Reducing the incidence of  stickshaker activations
• Going on site: the Bathurst Island investigation
• Bathurst Island accident
• Repcon briefs
• Download ATSB supplement (May-June 2011) [
  PDF: 954KB (928.37 KB)
  ]

March - April

• Lock and load
• No single fix for aircraft take-off errors
• Investigation briefs
• Aviation safety highlighted in bulletin
• Misaligned takeoff investigation
• Takeoff safety card
• Repcon briefs
• Download ATSB supplement (March-April 2011) [
  PDF: 1.1MB (1.72 MB)
  ]

January - February

• Risk of aviation oxygen cylinder rupture extremely remote
• QF30-how the investigation unfolded
• Investigation briefs
• QF32 investigation prompts early safety actions
• 747 engine failure and air turn-back
• Repcon briefs
• Download ATSB supplement (January-February 2011) [
  PDF: 3.1MB (2.72 MB)
  ]

ATSB Safety Issue Investigation: Queensland Coastal Pilotage

About the ATSB

The Australian Transport Safety Bureau (ATSB) is an independent Australian Government statutory agency. The Bureau is governed by a commission and is entirely separate from transport regulators and service providers. The ATSBs objective is safe transport and its function is to improve safety and public confidence in transport safety through excellence in safety investigations and research and
promulgating the lessons learned, safety actions and safety messages. It is not the purpose of ATSB investigations to apportion blame or provide a means for determining liability. The ATSB performs its functions in accordance with the provisions of the Transport Safety Investigation Act 2003 (TSI Act) and Regulations.

The Safety Issue Investigation

Background: In December 2010, following the completion of ATSB investigation MO-2009-001 into the grounding of the laden tanker Atlantic Blue in the Torres Strait in 2009, the ATSB initiated a safety issue investigation into Queensland's coastal pilotage operations. The findings of MO-2009-001 and two previous groundings in the Great Barrier Reef (GBR) since 1999 where a coastal pilot had conduct of the ship and numerous reports from coastal pilots about safety concerns indicate that significant safety issues may exist in coastal pilotage.

Reason and objective: The significant amount of cargo traded through ports along Australia's east coast makes shipping vital for the local and national economies. Coastal pilotage is the most important defence in place to reduce the risk of a shipping incident in the particularly sensitive GBR environment. Therefore, the safest possible coastal pilotage operations will benefit all industry stakeholders. A broad, systemic, ATSB safety issue investigation could identify issues that can make this objective more likely and improve safety and public confidence.

Scope: The investigation will focus on the safety management of pilotage operations, particularly the piloting procedures and practices of coastal pilots, including related motivational factors. Specific areas of existing safety management systems to be looked at will include pilot training and professional development, passage planning, standard piloting procedures, incident reporting, collision avoidance and the management of pilots' working hours. The investigation will also examine the effectiveness of the coastal pilotage regulations, the pilotage safety management code and the pilot assessment system in supporting safe and efficient pilotage operations.

The investigation will not focus on different models for the provision of pilotage services, commercial aspects not directly related to safety issues or analyse the costs or benefits of addressing safety issues that may be identified.

Investigation process: All investigation activities will be carried out under the provisions of the TSI Act which include the protection of certain information (restricted information). The ATSB will take into account various past reviews into coastal pilotage and collect information from licensed coastal pilots, stakeholders and interested parties. This will include a survey of all pilots, inviting submissions

from stakeholders and accepting submissions from other interested parties. A number of meetings will also be arranged with key stakeholders, coastal pilots and interested parties. Based on the evidence collected, a draft investigation report will be prepared and provided to relevant parties for comment. All comments received will be considered in finalising the investigation report and its findings.

Information and communication

Further information is available via the ATSB website and the links provided below:

Investigation MO-2009-001: Grounding of Atlantic Blue

Investigation MI-2010-011: Safety Issue-Queensland Coastal Pilotage

The coastal pilot survey form will be provided to coastal pilots for completion. Others can request a copy of the survey form if necessary.

ATSB Safety Issue Investigation: Queensland Coastal Pilotage

The Australian Transport Safety Bureau (ATSB) has written to the organisations listed in this document, requesting them to make submissions with respect to this safety issue investigation. Members and associates of these organisations are welcome to make submissions directly. The ATSB will also accept submissions from any other interested parties, including coastal pilots or pilot groups.

All submissions should be made in writing and received at the address below by the close of business on Friday, 28 January 2011.

Stakeholders and interested parties

• Australian Maritime Safety Authority
• Australasian Marine Pilots Institute
• Australian Reef Pilots Pty Limited
• Australian Shipowners Association
• ANL Container Lines
• ASP Ship Management Limited
• BP Australia Ltd
• Department of Transport and Infrastructure
• Great Barrier Reef and Torres Strait Vessel Traffic Service
• Great Barrier Reef Helicopter Group
• Great Barrier Reef Marine Park Authority
• Hydro Pilots Australia Pty Limited
• International Maritime Pilots Association
• Mackay Helicopters
• Maritime Safety Queensland
• Minerals Council of Australia
• National Bulk Commodities Group
• Perkins Shipping Pty Limited
• Ports Australia
• P&O Maritime Services
• Queensland Alumina Limited
• Queensland Sugar Limited
• Rio Tinto Shipping Pty Limited
• Shell Tankers Australia Pty Limited
• Shipping Australia Limited
• Teekay Shipping (Australia) Pty Limited
• The Nautical Institute
• Torres Pilots Pty Limited
• Torres Strait and Great Barrier Reef Pilots Limited - Sea Torres and Reef Pilots
• Whitsunday Helicopters

The ATSB can be contacted at:

Australian Transport Safety Bureau
Manager, Surface Safety-Canberra
PO Box 967
Civic Square ACT 2608

Email: marine@atsb.gov.au

Telephone: (02) 6274 7033 (Manager, Surface Safety-Canberra)

Failure of a Responsible Person to Report under Sections 18 and 19 of the Transport Safety Investigation Act 2003

Where it is apparent that a Responsible Person has failed to provide a report in accordance with the requirements in sections 18 or 19 of the TSI Act, the circumstances of the apparent failure will be assessed to determine the appropriate action to be taken. Appropriate action will be based on two options:

(a)  educate the responsible person, or class of responsible persons, to ensure compliance in the future; or

(b)  refer the apparent breach to the Australian Federal Police (AFP) for investigation, with the potential for a brief of evidence to be provided by the AFP to the Commonwealth Director of Public Prosecutions (CDPP) to assess for possible prosecution action. In certain circumstances, the referral may instead be made to state police force, or to a police force with jurisdiction to investigate the apparent breach.

The ATSB's policy is that the option of education is to be used where the apparent breach does not meet the criteria for referring it to the AFP(Opens in a new tab/window) for investigation.  However, it is expected that there will be relatively few circumstances where the matter is referred to the AFP.  The matter must be serious.

Where there is an apparent breach of section 18 or 19 of the TSI Act it is likely that it would only be considered serious if:

(a)  the Responsible Person was aware of their reporting obligations, or should have in the circumstances been aware of their reporting obligations, and there is evidence to indicate that the Responsible Person:

i.     deliberately decided not to report in accordance with their obligations; or
ii.     was reckless in their failure to report; and

(b)  the matter or matters required to be reported:

i.    had serious safety consequences, or narrowly avoided serious safety consequences, for a person or persons and is a matter or matters that the ATSB would investigate; or
ii.    constituted a number of less serious matters, but which because of their number represent a poor approach to safety reporting by the Responsible Person; and

(c)   an investigation by the AFP, with potential prosecution by the CDPP, is thought necessary to deter:

i.    the Responsible Person from failing to report in the future; or
ii.    other Responsible Persons from failing to report.

As a minimum, the circumstances should be consistent with the above criteria for the matter to be referred to the AFP with the intention of it then being prosecuted by the CDPP.

Mr Angus Mitchell

CHIEF COMMISSIONER AND CEO

Angus Mitchell has extensive experience in organisational leadership and management, maritime operations and safety investigation.

He joined the ATSB from Maritime Safety Queensland, where as General Manager he oversaw the safe and efficient movement of vessels into and out of Queensland’s 21 ports, and was responsible for compliance activities and safety investigations for Australia’s largest recreational maritime fleet.

During his tenure, Maritime Safety Queensland was recognised with an Australian Industry and Shipping Award for its role in managing international shipping throughout the COVID pandemic and supporting the welfare and safety of international seafarers.

Prior to leading Maritime Safety Queensland, Mr Mitchell was the Executive Director of NSW Maritime, where he oversaw Australia’s largest state’s primary maritime regulatory, investigative and compliance agency. He has also served as Deputy Harbour Master – Operations for Sydney Ports, where he was responsible for managing day-to-day port operations for both Sydney Harbour and Port Botany.

Angus is a former officer of the Royal Australian Navy having seen service in operational, policy and international roles. He is an Indonesian linguist and commenced his five-year term as ATSB Chief Commissioner and Chief Executive Officer on 2 September 2021.

Mr Peter Wilson

COMMISSIONER

Peter Wilson commenced his professional piloting career with Qantas in 1985. Over the following 20 years, Mr Wilson held a number of key senior management appointments including Senior Check Captain Boeing 767, General Manager of Boeing 767 Operations and General Manager of Airbus A330 Operations.

Mr Wilson also held the senior executive appointments as Qantas’s Chief Pilot and Chief Operating Officer.

Since retiring from Qantas, Mr Wilson has worked as a professional consultant, served as the interim CEO and Chief Operating Officer of Tigerair and held other senior executive appointments more broadly.

Mr Wilson was appointed a Commissioner of the Australian Transport Safety Bureau in August 2023.

Ms Julie Bullas

COMMISSIONER

Julie Bullas has significant operational experience and achievements involved in rail safety and rail regulation at the state and national level.

Before joining the ATSB Commission Ms Bullas served for 10 years as Executive Director, Policy, Reform and Stakeholder Engagement at the Office of the National Rail Safety Regulator (ONRSR), and before which she was project director for the National Rail Safety Regulator Project.

Prior to working with the national rail regulator, Ms Bullas was the road/rail interface specialist for Queensland Rail, and the Director of Rail Safety for Queensland Transport.

Ms Bullas was appointed a Commissioner of the Australian Transport Safety Bureau in October 2023.

VADM Russell Crane 

COMMISSIONER

Vice Admiral Russell Crane AO, CSM, ret’d is a former Chief of Navy, and as such is a highly experienced mariner and with extensive experience as a senior leader.

VADM Crane served as Chief of Navy between July 2008 and June 2011, during which time he initiated the New Generation Navy program and established the inaugural RAN Seaworthiness program. 

His Navy service also included three seagoing commands (including of HMAS Success, then the largest vessel in the Navy), and serving as Commander of the Navy Systems Command, Director General Coastwatch, and Deputy Chief of Navy.

Since retiring from the Navy, he has held a number of board and advisory positions.

VADM Crane was appointed a Commissioner of the Australian Transport Safety Bureau in December 2025.

The Australian Transport Safety Bureau is committed to improving the accessibility of web content. To provide feedback or request an accessible version of a document please contact us.

atsb.gov.au is currently compliant to Level AA of the Web content accessibility guidelines version 2.0 - external site(Opens in a new tab/window) (WCAG 2.0) standard. WCAG was developed by the World Wide Web Consortium (W3C) and has been designed to support accessibility hardware and/or software that our users may use. This site is being upgraded to conform to WCAG 2.2.

If any information or service provided by atsb.gov.au is inaccessible to you or you are experiencing problems accessing content for any reason, please contact us.

Browsing our site

Browser requirements

To ensure your security and the best experience with this site, we recommend you update your browser to the latest version. 

Big and small screens are supported 

Our website has been designed to work on devices of all shapes and sizes. You will get a similar experience if you are working on your phone, a tablet, a laptop or a desktop. 

Searching the website

You can search our website using the search bar at the top of every page.

Subsection 25(1) of Part 4 of the Transport Safety Investigation Act 2003.

25  Reports on investigations

(1)     The ATSB must, as soon as practicable after an investigation has been completed, publish, by electronic or other means, a report in relation to the investigation.

(2)     The ATSB may, at any time before an investigation has been completed, publish, by electronic or other means, a report in relation to the investigation if it considers that the publication of the report is necessary or desirable for the purposes of transport safety.

(3)     A published report may include submissions that were made by persons to the ATSB in response to a draft report, safety action statements or safety recommendations.

(4)     A published report must not include the name of an individual unless the individual has consented to that inclusion.

(5)     In this section:

report means any one or more of the following:

(a)         a report;

(b)         safety action statements;

(c)         safety recommendations.

25A  Responses to reports of, or containing, safety recommendations

(1)     This section applies if:

(a)         the ATSB publishes a report under section 25 in relation to an investigation; and

(b)         the report is, or contains, a recommendation that a person, unincorporated association, or an agency of the Commonwealth or of a State or Territory, take safety action.

(2)     The person, association or agency to whom the recommendation is made must give a written response to the ATSB, within 90 days of the report being published, that sets out:

(a)         whether the person, association or agency accepts the recommendation (in whole or in part); and

(b)         if the person, association or agency accepts the recommendation (in whole or in part)-details of any action that the person, association or agency proposes to take to give effect to the recommendation; and

(c)         if the person, association or agency does not accept the recommendation (in whole or in part)-the reasons why the person, association or agency does not accept the recommendation (in whole or in part).

(3)     A person commits an offence if:

(a)         the person is someone to whom a recommendation is made in a report published under section 25; and

(b)         the person fails to give a written response to the ATSB within 90 days setting out the things required by paragraphs (2)(a), (b) and (c) (as applicable).

Penalty:   30 penalty units.

(4)     Subsection (3) applies to an unincorporated association as if it were a person.

(5)     An offence against subsection (3) that would otherwise be committed by an unincorporated association is taken to have been committed by each member of the association's committee of management, at the time the offence is committed, who:

(a)         made the relevant omission; or

(b)         aided, abetted, counselled or procured the relevant omission; or

(c)         was in any way knowingly concerned in, or party to, the relevant omission (whether directly or indirectly or whether by any act or omission of the member).

26  Draft reports

(1)     The ATSB may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate, for the purpose of:

(a)         allowing the person to make submissions to the ATSB about the draft report; or

(b)         giving the person advance notice of the likely form of the published report.

(2)     A person who receives a draft report under subsection (1) or (4) must not:

(a)         make a copy of the whole or any part of the report; or

(b)         disclose any of the contents of the report to any other person or to a court.

Penalty:

(a)         in the case of a contravention of paragraph (a) - 20 penalty units; or

(b)         in the case of a contravention of paragraph (b) - imprisonment for 2 years.

(3)     Strict liability applies to the element of the offence against subsection (2) that the draft report is received under subsection (1) or

(4)     Subsection (2) does not apply to any copying or disclosure that is necessary for the purpose of:

(a)         preparing submissions on the draft report; or

(b)         taking steps to remedy safety issues that are identified in the draft report.

Note: A defendant bears an evidential burden in relation to a matter in subsection (4). See subsection 13.3(3) of the Criminal Code.

(5)     A person who receives a draft report under subsection (1) or (4) cannot be required to disclose it to a court.

(6)     A person who receives a draft report under subsection (1) or (4) is not entitled to take any disciplinary action against an employee of the person on the basis of information in the report.

(7)     A draft report provided under subsection (1) must not include the name of an individual unless the individual has consented to that inclusion.

Australia’s reputation for high quality and rigorous investigations makes us uniquely placed to assist transport safety in the Asia Pacific region, and the ATSB has an active program of regional engagement with other transport safety agencies, over and above that required by our international obligations.

Providing assistance to our regional neighbours helps strengthen their transport safety capabilities and meeting their international obligations related to transport safety. As well as promoting Australia's standing in the region and upholding our broader international obligations, it is in Australia's best interests to work for stability, safety and security in the countries that are our regional neighbours.

The type of capability building support that the ATSB is able to provide includes advice and guidance related to:

• legislation and regulations for accident notification and investigation related activities
• investigation function/agency structure and staffing
• investigation function/agency policy and procedures
• training for investigators and investigation support staff

The ATSB carries its out regional engagement work in a way that is unbiased, open, and accountable. We work with our counterpart agencies to develop programs that are mutually beneficial and that take appropriate account of local conditions and sensitivities.

The ATSB has specific programs of cooperation with the Indonesian National Transportation Safety Committee (NTSC) and the Papua New Guinea (PNG) Accident Investigation Commission (AIC). In 2024, the ATSB also began working within Australia-Pacific Partnerships for Aviation Program (P4A). These activities are supported by funding from the Australian Government Department of Foreign Affairs and Trade (DFAT). 

Indonesia

In March 2007, a Boeing 737 overran the runway while attempting to land at Yogyakarta airport, central Java. The accident claimed 21 lives, with others receiving serious injuries. Five of those who lost their lives were Australians. This tragic accident led to the development of the Australian Government’s Indonesia Transport Safety Assistance Package (ITSAP).

Under ITSAP, Australia has worked closely with the Government of Indonesia to develop a package of measures to address areas identified by Indonesia as its key transport safety priorities.

The main elements of the ATSB's contribution to ITSAP have been to deliver training and support for investigators from the ATSB's Indonesian counterpart agency, the National Transportation Safety Committee (NTSC). This includes the ATSB providing staff dedicated to various capacity building projects, funding training courses, and opportunities for aviation, marine, and rail investigators to work with their ATSB counterparts.

Papua New Guinea

Under the Australia-PNG Memorandum of Understanding on Cooperation in the Transport Sector, the ATSB has a program of cooperation and capability building with the PNG Accident Investigation Commission (AIC).

Enhancing the capability of PNG to carry out aviation safety investigations in a thorough and timely manner enables the identification of areas of safety concern and promotes safety action. The ATSB continues to support the AIC through identified areas of cooperation.

Australia-Pacific Partnerships for Aviation Program

Through the Australia-Pacific Partnerships for Aviation Program (P4A), the ATSB works with Pacific States to strengthen safety investigations through training and capability enhancement. This includes a range of initiatives such as establishing cooperation mechanisms with aviation agencies, improving institutional capability and ensuring that transport safety is aligned with global standards.

The ATSB has developed and is delivering a suite of face-to-face and virtual training packages, and will continue to work with Pacific States to build technical expertise to respond to local aviation incidents and accidents and promote regional aviation safety.

Australia's international obligations

The ATSB's program of regional engagement is in line with the philosophy and initiatives of both the International Civil Aviation Organization (ICAO) and the International Maritime Organization (IMO).

The ICAO framework

The very nature of ICAO rests on the notion of international cooperation. The Chicago Convention on International Aviation was based on the ideal of promoting "cooperation between nations and peoples".

ICAO promotes cooperation between Contracting States in all matters relating to civil aviation. There is an acknowledgement that some ICAO States lack the resources to comply with ICAO standards and recommended practices on their own, and that the international community has a responsibility to assist those States to meet acceptable standards.

The IMO framework

The IMO places significant emphasis on cooperation between States. For example, the IMO has an extensive Technical Co-operation Programme which concentrates on improving the ability of developing countries to help themselves. The program concentrates on developing human resources through maritime training and similar activities.

ATSB operational benefit

Australia often needs to work cooperatively with other States in order to achieve its objectives. The ability to do this is significantly enhanced by building good relationships with the safety investigation agencies of other States, so that when an accident occurs the ATSB already has effective mechanisms in place to facilitate good communication and cooperation.

Requests for Tender

All open Requests for Tender (RFTs) are available via the AusTender website.

AusTender is the online tendering system for Australian Government Agencies. AusTender allows tenderers to download tender documentation. Tenderers must first register with AusTender(Opens in a new tab/window).

Further guidance: The Department of Finance provides information to help business identify opportunities and compete for government business which can be found at: Selling to Government(Opens in a new tab/window).

Annual Procurement Plan

In accordance with the Commonwealth Procurement Rules, the ATSB has published an Annual Procurement Plan on AusTender.

• ATSB Annual Procurement Plan(Opens in a new tab/window)

Agency Contracts over $100,000 

ATSB's procurement contracts listing is available through the Senate Order link located on the AusTender Homepage tenders.gov.au(Opens in a new tab/window)

The ATSB's Accountable Authority has assured that the listed contracts do not contain any inappropriate confidentiality provisions.