The ATSB collects, holds and uses a range of information for the purposes of improving transport safety. The ATSB is a part of Australia's aviation safety system and the information gathered by the ATSB may be provided to other agencies for the specific purpose of maintaining and improving aviation safety. It is an additional legislative function for the ATSB to cooperate with these agencies.

Mandatory reporting

A principal source of safety information is the mandatory reporting scheme established under the Transport Safety Investigation Act 2003 (TSI Act). The scheme gathers information on occurrences which endanger or could endanger aviation safety. The information is gathered so that it can be used by those with responsibilities within the safety system to discharge their responsibilities to maintain and improve aviation safety.

The scheme requires 'responsible persons' (including aircraft crew, owners, operators, air traffic controllers, licensed aircraft maintenance engineers, ground crew and airport operators) to notify the ATSB of accidents and safety incidents ('safety occurrences').

Where the duty to report rests with an individual, it can be fulfilled by the individual notifying the operator who employs them. The operator then has a duty to pass the information on to the ATSB.

Use of safety information by the ATSB

The ATSB uses safety information to assist in its determination of what to investigate for the purposes of improving safety.

Any information that is the subject of an ATSB investigation will only be used in accordance with the provisions of the TSI Act which provides significant protections to information acquired by the Bureau in the course of its investigation.

The ATSB also uses safety information for the purposes of safety research and analysis. The results of research and analysis are generally made public, but in such a way that either the information is either de-identified or is otherwise protected.

ATSB and CASA information sharing

The Civil Aviation Safety Authority (CASA) is constituted under the Civil Aviation Act 1988 (CA Act). The primary object of the CA Act is to establish a regulatory framework for maintaining, enhancing and promoting the safety of civil aviation, with particular emphasis on preventing aviation accidents and incidents. CASA's primary function under the CA Act is to conduct the safety regulation of civil air operations in Australia and the operation of Australian aircraft outside Australian territory.

Consistent with the objective of maintaining and improving aviation safety under the Australian aviation safety framework, the ATSB recognises CASA needs access to a range of information about aviation safety occurrences that is collected and held by the ATSB.

What information is shared

The ATSB informs CASA about accidents and serious incidents as soon as the ATSB is informed. The information may contain details such as operator names, registration numbers, times, dates, locations and a description of the event. The ATSB aims, wherever possible, to avoid directly identifying individuals.

CASA is also provided daily with a redacted report of all occurrences entered into the ATSB database. The report contains standard information about occurrences notified to the ATSB, including aircraft registration, so that CASA has enough detail to gather its own information about the occurrence. It does not contain a detailed narrative.

An automated weekly transfer of summaries of information entered in the ATSB's database during that week is also provided to CASA. The aggregate summary does not include identifying information such as aircraft registration, but provides enough information for CASA to be able to analyse safety trends, and to identify actual or potential safety risks to which more immediate attention needs to be directed.

Purpose of information sharing

CASA uses safety information from the ATSB principally for two purposes: to have sufficient information about an occurrence to decide whether to initiate its own, independent regulatory inquiries; and to maintain a database of occurrence information so that trends in aviation safety can be detected and, where necessary, safety action can be taken.

Limits on use of information by CASA

CASA may use information reported under the mandatory scheme as the basis for informing its need to initiate its own inquiries in the interests of safety. However, CASA will not rely on the report in taking action unless it is necessary to do so in the demonstrable interests of safety and where there is no alternative source of the information practicably available to CASA.

CASA will not normally recommend the institution of criminal proceedings in matters which come to its attention only because they have been reported under ATSB's mandatory reporting scheme. The exceptions will be in cases of conduct that should not be tolerated, such as where a person has acted intentionally, knowingly, recklessly or with gross negligence.

In taking any action, CASA will afford affected individuals and organisations natural justice.

REPCON is a voluntary and confidential reporting scheme. REPCON allows any person who has a rail safety concern to report it to the ATSB confidentially. Protection of the reporter’s identity and any individual referred to in the report is a primary element of the scheme.

Personal information will not be disclosed. Only de-identified information will be used for safety action. You may be contacted for additional information.

The following matters are not reportable safety concerns and are not guaranteed confidentiality:
a) matters relating to a serious and imminent threat to a person’s health or life
b) terrorist acts
c) industrial relations matters
d) conduct that may constitute a serious crime.

NOTE 1: REPCON is not an alternative to the mandatory reporting requirements detailed in sections 18 and 19 of the Transport Safety Investigation Act 2003.  

NOTE 2: Submission of information known by the reporter to be false or misleading is a serious offence under section 137.1 of the Criminal Code. Aiding, abetting, counselling, procuring or urging the submission of false or misleading information is also a serious offence.

Since March 2013, the Multicultural Access and Equity Policy(Opens in a new tab/window) requires that all Australian Government departments and agencies under the Financial Management and Accountability Act 1997, with the exception of the Departments of the Parliament, have an Agency Multicultural Plan in place and available on their websites in mid-2013. 

The ATSB Multicultural Plan 2013-2015  [

Safety concern

ATSB research reveals that accidents and incidents are not always reported to the ATSB when they should be. When something goes wrong in transport safety, it is the duty of a ‘responsible person’ (defined in the Transport Safety Investigation Regulations 2003) to report it to the ATSB. 

ATSB on YouTube(Opens in a new tab/window)

What can you do?

As the national transport safety investigator, the ATSB is the Australian Government agency you should notify in the event of an accident or incident.

While we use your notification to determine whether to investigate an occurrence, looked at as a whole, notifications also give us a bigger picture of aviation safety trends and patterns.

Like a jigsaw piece in a bigger puzzle, certain notifications can often be joined together to reveal a broader, systemic safety problem. Once we've identified an accident or incident trend from your notifications, we can make tangible improvements to safety through safety advisory notices, recommendations and further safety investigations.

Besides the obvious safety benefits of reporting an occurrence, there are also legal requirements to report certain accidents and incidents to the ATSB. Even if there are no injuries or there is minimal aircraft damage, you must still let the ATSB know. Remember that the ATSB does not investigate to lay blame or apportion liability—we investigate to improve safety and prevent an accident from happening again.

You can report an accident or serious incident (an Immediately Reportable Matter — IRM) to the ATSB 24 hours a day, seven days a week:

• call 1800 011 034 (you can also use this number if you need advice or clarification on reporting matters)
• submit a written report — Submit a Mandatory Notification

More information

Find out how and what to report to the ATSB. 

ATSB research report Under reporting of aviation wirestrikes illustrates the scale of under reporting that can occur.

Safety concern

The ATSB has investigated several accidents that have occurred when maintenance work was being carried out on or near railway tracks. Conducting work on or near a railway track can be dangerous if safeworking rules and procedures have not been correctly implemented to protect the worksite. Trains cannot stop quickly and any breakdown in the communication or management of a worksite can leave workers extremely vulnerable to dangerous situations.

What can you do?

Operational safe working on track requires a high level of preparation and organisation. Whenever there is work taking place on or near a track, coordination and communication are essential. Before authority is granted to occupy or work near a track, it is essential that all information is clearly communicated and verified between the Protection Officer and the Network Control Officer.

An adequate briefing about the work site and effective communications equipment must be made available to the track workers. For track workers, it is vital to ensure that all levels of worksite protection have been fully implemented before commencing work on or near the track.

More information

The following ATSB investigations into accidents involving work on railway tracks, shows the importance of good work practices, coordination and communication:

• Collision between a coal train and an excavator at Maitland NSW on 20 December 2011
• Collision between freight train 7SP3 and a track-mounted excavator near Jaurdi, WA, 28 March 2011
• Collision between XPT passenger train WT27 and a track-mounted excavator near Newbridge, New South Wales, 5 May 2010

Safety concern

It is difficult for pilots to spot another aircraft through visual observation alone. 

The ATSB often receives reports from pilots that another aircraft is flying too close to them in uncontrolled airspace. Not surprisingly, three quarters of these reports involve pilots flying within 10 nautical miles (18.5 kilometres) of a non-controlled aerodrome.

Twice as many near-collisions are reported to the ATSB where pilots had no prior warning of other aircraft in their vicinity, compared with situations when a pilot received an alert by radio or a traffic alerting system like TCAS.

Insufficient communication between pilots operating in the same area is the most common cause of safety incidents near non-controlled aerodromes. 

ATSB on YouTube(Opens in a new tab/window)

What can you do?

• Get a radio, and always make sufficient broadcasts so that other pilots know your intentions – even when you think there is no nearby traffic. This will increase your chance of detecting other aircraft before it's too late. Making at least the minimum radio broadcasts and using good radio practice alerts other pilots to nearby aircraft and help to reduce the risk of a mid-air collision or a near miss.
• Maintain a lookout for other aircraft at all times. There may be a variety of aircraft of different sizes and performance levels all operating at the same time in the same airspace, and some aircraft may not have a radio that is working or is tuned to the correct frequency. Do not rely solely on monitoring your radio to achieve traffic awareness. 
• Achieve radio alerted see-and-avoid by making all the recommended broadcasts within 10 nautical miles of a non-towered aerodrome. A search for other traffic is eight times more effective when a radio is used in combination with a visual lookout than when no radio is used.
• Use the same procedures at all non-towered aerodromes, unless otherwise stated in the En Route Supplement Australia. Following known, standard traffic procedures helps pilots to anticipate the likely position of other aircraft.
• Be aware that any radio-equipped aircraft could be conducting base leg entry or straight-in approaches at non-towered aerodromes. Large commercial jet aircraft landing at non-towered aerodromes often make straight-in approaches, but any VHF radio-equipped aircraft are allowed to make these types of approaches.
• Avoid overflying aerodromes where possible, and take note of instrument flight rules inbound and outbound routes. Aircraft traffic is relatively dense near aerodromes, particularly on the final approach path to an active runway and on the runway itself.

More information

The booklet A pilot’s guide to staying safe in the vicinity of non-controlled aerodromes outlines many of the common problems that occur at non-controlled aerodromes, and offers useful strategies to keep yourself and other pilots safe. You can also order free hardcopies at atsbinfo@atsb.gov.au 

The Civil Aviation Safety Authority (CASA) has produced several publications and resources that provide important safety advice for

Safety concern

R44 helicopters with all-aluminium fuel tanks have proven susceptible to post-accident fuel leaks increasing the risk of a potentially fatal post-impact fire following a collision with terrain. 

What can you do?

The manufacturer has issued a Service Bulletin SB-78B(Opens in a new tab/window) requiring R44 helicopters with all-aluminium fuel tanks be retrofitted with bladder-type tanks as soon as practical, but no later than 30 April 2013.

The ATSB urges all operators and owners of R44 helicopters fitted with all-aluminium fuel tanks to replace these tanks with bladder-type fuel tanks as detailed in the manufacturer's Service Bulletin 78B as soon as possible.

The fitment of bladder-type fuel tanks to R44 helicopters is a very important safety enhancement that could save lives. The ATSB has also suggested that regulators and investigation agencies in other countries consider what steps they can take to increase compliance with the manufacturer’s safety bulletin.

More information

The ATSB issued a Safety Advisory Notice on 9 March 2012, advising of the potential dangers of the all-aluminum fuel tank. 

As part of its preliminary report release on a fatal R44 accident at Bulli Tops in NSW, the ATSB issued a Safety Recommendation to the Civil Aviation Safety Authority (CASA) on 5 April 2013. The ATSB recommended CASA take further action to ensure R44 helicopter operators are aware of regulatory requirements for retrofitting the fuel tank with the bladder-type tank. 

In response CASA issued an Airworthiness Bulletin(Opens in a new tab/window) to ensure that all owners, operators and maintainers are aware of the requirements to comply with the manufacturer’s service bulletins.

The ATSB also highlights Service Bulletin SB-82(Opens in a new tab/window) that aims to reduce the chance that the rotor brake switch will act as a possible ignition source in the event of a fuel leak.

Three fatal helicopter accidents also illustrate the potential danger:

• Loss of control - Robinson R44 helicopter, VH-HFH, Cessnock Aerodrome, NSW, 4 February 2011
• Collision with terrain - Robinson R44, VH-COK, Jaspers Brush, NSW, 4 February 2012
• Collision with terrain involving Robinson R44 helicopter, VH-HWQ at Bulli Tops, near Wollongong NSW on 21 March 2013

Safety concern

Navigation through confined waters under pilotage is a high-pressure situation where errors can easily lead to serious incidents. 

What can you do?

The clear and open exchange of information between the ship’s master and crew and the pilot is vital, both during the pilotage passage and before it even commences. This helps to ensure that all members of the bridge team have a shared mental model of the pilotage passage and, as a result, a good understanding of how it should proceed. 

This pre-passage information exchange should always include: 

• the courses or tracks to be followed 
• speeds at critical points during the pilotage 
• limits in relation to planned tracks and speeds. 

It should also include information on the ship’s handling characteristics and the state of critical equipment such as navigation systems, steering gear, main engine and bow thrusters.

Clear communication is also essential during the passage itself. This is to ensure that the members of the navigation team—including the pilot, bridge team and engineers on duty in the engine room—understand their roles and responsibilities and that instructions are fully understood and correctly actioned. Every member of the team must be free to speak up or “challenge” if they notice something abnormal or they feel that something is amiss.       

In addition, a pilotage situation represents a complex environment. This complexity, combined with long hours and the need for precision, can cause fatigue. Precautions must be taken to prevent errors. Especially useful is a fatigue management plan that predicts potential fatigue levels at key positions in the pilotage task and that allows for strategic preparation.

ATSB on YouTube(Opens in a new tab/window)

More information

A number of ATSB marine investigation reports have highlighted problems that can arise in the course of a pilotage:

• Grounding of the Hong Kong-registered products tanker Atlantic Blue at Kirkcaldie Reef in the Torres Strait on 7 February 2009 
• Collision between the Australian fishing vessel Apollo S and the Liberian-registered bulk carrier Grand Rodosi in Port Lincoln on 8 October 2010 
• Grounding of the Panama registered bulk carrier Dumun at Gladstone, Queensland, on 29 April 2011 

Following the investigation into the grounding of the Atlantic Blue in 2010, the ATSB completed a safety issue investigation into Queensland coastal pilotage operations. The report identifies six significant safety issues in coastal pilotage operations. 

Safety concern

The ATSB has investigated several incidents involving unsafe working practices in the maritime industry. These incidents resulted in serious injury or death following falls from height, crushing and equipment that exploded.  

The most common problem associated with these incidents was the fact that the people involved in the task did not properly identify the risks involved before they started the task. Sometimes risk strategies were not implemented, and in some cases, individuals ignored established procedures. To some degree, these incidents involved the people being complacent about the task and this complacency was the direct cause of the injury or fatality.

ATSB on YouTube(Opens in a new tab/window)

What can you do?

For most tasks, a comprehensive risk control plan is vital. Ensure that you follow a plan and the established procedures for any task that has risk. Make certain that you know how to do the tasks that have been assigned to you and if you are uncertain about the procedures, talk to your supervisor about your concerns. Remember, safe work procedures are ‘good’ rules to follow and are there to make your workplace safer.

Take the time to evaluate the task you are about to do. Take the time to think about the risks, and what you’re going to do to manage them. 

More information

The following ATSB safety investigations show and examine the risks of unsafe working practices, and provide important safety messages for maritime workers and operators, both ashore and at sea:

• Stevedore fatality on board the Antigua and Barbuda registered container ship Vega Gotland at Port Botany, New South Wales, 28 March 2010.
• Fatality at sea on board the Liberian registered multipurpose ship Cape Darnley on 8 July 2010.
• Crew member fatality on board the bulk carrier Polska Walczaca at sea off Queensland on 15 November 2010.
• Thermal oil heater explosion on board the products tanker Qian Chi at Brisbane, Queensland, 16 January 2011.
• Crew member fatality following a fall on board the bulk carrier Hanjin Sydney at sea, 2 February 2011.
• Serious injury to a crew member on board Spirit of Tasmania I, 17 September 2011.
• Serious injury to a crew member on board the Panamanian registered bulk carrier Universal Gloria, at sea off Eden, NSW on 11 October 2011.

Safety concern

An increasing trend has been identified where pilots mishandle or mismanage their aircraft and flight profile when unexpected events arise during the approach to land. When compared to other phases of flight, the approach and landing has a substantially increased workload. Pilots and crew must continuously monitor aircraft and approach parameters, and the external environment to ensure they maintain a stable approach profile and make appropriate decisions for a safe landing.

Unexpected developments, or any confusion about roles or procedures can contribute to decisions and actions that increase the safety risk to the aircraft and its passengers.

ATSB on YouTube(Opens in a new tab/window)

What can you do?

Standard operating procedures ensure consistency of crew interaction and aircraft operation during an approach and landing.

Make sure you are familiar with the procedures for the approach well ahead of time. If you have any concerns or observe any deviations from the briefed approach, communicate this to the other flight crew without hesitation.

Good communication is vital. If there is any confusion or uncertainty, clarify the situation and take timely action to rectify any deviations before they become a problem.

If there is any doubt about the safety of the aircraft, conducting a go-around is a perfectly legitimate option. Safety trumps scheduling or dignity.

More information

A number of occurrences during the approach to land have been investigated by the ATSB:

• Hard landing - Darwin Airport, Northern Territory, 7 February 2008, VH-NXE, Boeing Company 717-200 | ATSB
• Stickshaker activation – Boeing 717-200, VH-NXE, Alice Springs, Northern Territory, on 18 September 2008 | ATSB
• Unstable approach of a Bombardier DHC8, VH-TQL, Sydney Aerodrome, New South Wales, on 26 December 2008 | ATSB
• Stall warning device event - Bombardier Inc DHC-8-315, VH-TQL, Sydney Airport, New South Wales, on 1 March 2011 | ATSB
• Go-around event Melbourne Airport, Victoria, on 21 July 2007, VH-VQT, Airbus Industrie A320-232 | ATSB