The ATSB Annual Report 2014–15 outlines performance against the outcome and program structure in the 2014–15 Infrastructure and Regional Development Portfolio Budget Statements.

Chief Commissioner’s review 2014–15

This was the ATSB’s sixth year as a fully independent body within the Infrastructure and Regional Development portfolio. In addition to the continuing search for the missing Malaysia Airlines Flight MH370, 2014–15 saw the completion of a range of significant investigations and some significant governance changes for the ATSB.

In July 2013, I requested the Transportation Safety Board of Canada (TSB) to conduct an independent objective review of our safety investigation methodologies and processes. I asked that they benchmark Canadian methodologies with ours and compare both with international standards. The TSB looked, in particular, at three of our substantial investigations including the ditching of a Pel-Air Westwind jet off Norfolk Island in 2009 (AO-2009-072). This investigation had been strongly criticised in some quarters and was the subject of a report by the Senate Rural and Regional Affairs and Transport Committee.

The TSB report, released in December 2014, found that the ATSB’s investigation methodology and analysis tools represent best practice, and have been shown to produce very good results.

At the same time, the report highlighted room for improvement, particularly in relation to the way our processes were applied to the Pel-Air ditching investigation.

In response to the TSB review, the ATSB decided to reopen the investigation into the Pel‑Air accident. A completely new team was appointed to review the original investigation and associated report in light of any fresh evidence, relevant points from the TSB review and other recent aviation reviews. The ATSB expects to complete the reopened investigation in the first quarter of 2016.

After carefully considering the other findings and recommendations of the TSB report, the ATSB accepted all of them. We have worked our way methodically and carefully through implementation of the recommendations of the TSB review, resulting in improvements to the future work of the ATSB. Being able to compare our approaches and learn from our respected colleagues in Canada has been a valued opportunity.

In November 2013, in keeping with a pre-election commitment, the Deputy Prime Minister and Minister for Infrastructure and Regional Development, the Hon Warren Truss MP, commissioned a review of Australia’s aviation safety regulation system. This was to see how our safety regulation system is placed to deal with this economically important industry. Following completion of the report the ATSB contributed to the Government’s response.

On 3 December 2014, the Deputy Prime Minister made a statement in Parliament confirming that the Government fully supports the vital role of the ATSB. To give effect to a pre-election commitment, he undertook to appoint an additional Commissioner with aviation experience and to issue a new Statement of Expectations.

In accordance with the Deputy Prime Minister’s announcement, Mr Chris Manning was appointed as a Commissioner with effect from 9 March 2015. Chris has brought a wealth of experience in aviation as an expert pilot and prominent aviation manager, and from his arrival has made a very valuable contribution to our work.

The Deputy Prime Minister issued a revised Statement of Expectations on 19 April 2015. The statement largely confirmed our existing focus and direction, but also required us to implement the relevant parts of the Government’s response to the Aviation Safety Review Report and the agreed recommendations of the TSB review. The ATSB’s response to the Statement of Expectations is set out in our Corporate Plan.

The issuing of a Corporate Plan was part of our implementation of the Public Governance, Performance and Accountability Act 2013 (PGPA Act). To meet the requirements of the new PGPA Act, we have implemented more comprehensive business planning and risk management processes. These are all being managed consistently with our safety priorities, which have been at the centre of our SafetyWatch communication and safety awareness direction for the last three years.

The search for Malaysia Airlines Flight MH370

The search for the missing Malaysia Airlines Flight MH370 in the Southern Indian Ocean has been a major commitment during the whole year. It has involved complex and challengingactivities including:

  • conducting ground-breaking technical analysis to determine the appropriate search area
  • determining the processes and standards necessary to undertake an unprecedented underwater search
  • selecting highly capable contractors with the expertise and equipment to conduct the search
  • continuing project and financial management
  • dealing with the incredible level of interest and enquiry from all over the world.

We have worked with our Minister and our Malaysian and Chinese counterparts to keep them informed of the search progress and enable joint decisions to be made when required.


During the year we completed 40 aviation investigations and more than 100 short factual investigations.

The most significant of these was the crash of a Robinson R44 helicopter at Bulli Tops on 21 March 2013 (AO-2013-055). This, as well as two previous similar accidents involving R44 helicopters, highlighted the danger of rigid fuel tanks in low-impact helicopter crashes, where post-impact fires may make otherwise survivable accidents deadly. We confirmed this trend with detailed statistical analysis of similar accidents in Australia and the US over a 10-year period.

While the Civil Aviation Safety Authority (CASA) had recommended that owners and operators implement the manufacturer’s service bulletin recommendation to replace the fuel tanks with bladder-type tanks that would improve resistance to post-impact fuel leaks, it was clear that they would be unlikely to meet the 30 April 2014 deadline. Accordingly, the ATSB recommended that CASA mandate the requirement by the due date. As a result, all R44 helicopters in Australia are now compliant.

Following this action, other safety authorities in South Africa, New Zealand and Europe have also mandated the change. The ATSB has issued safety recommendations to the US Federal Aviation Administration that they also take action to mandate fitting of bladder-type fuel tanks. The outcome of this investigation illustrates the importance of our investigations and the far-reaching influence safety investigations can have in ensuring transport safety for all travellers, not only those in Australia or our immediate region.

Other significant aviation investigations have also led to improvements in the way air ambulance and rescue services undertake winching of patients. There have also been changes to air traffic control procedures and training of air traffic controllers following our investigation into a loss of separation assurance.


During the year we completed five marine investigations. These were mainly concerned with marine work practices and confirmed that ships are inherently dangerous places of employment.

It is essential that employees implement sound risk management and occupational health practices. The most serious of these incidents was the unexpected deployment of a lifeboat and the subsequent serious injury to an employee.

Errors by maritime pilots and other ship operators are still contributing to collisions and other mishaps.


We completed 20 rail investigations this year. Some of these concerned derailments, raising serious questions about the way operators are building and maintaining their rail networks.

Disappointingly, we are still seeing many instances where breaches of safe work practices put maintenance crews and operators at risk. This issue has been one of our safety priorities for the last three years. Continuing notifications suggest the existence of broader safety issues associated with work on track. Consequently, we have initiated a safety issues research project looking into the protection issues that provide for safe work on track. The project has commenced with an analysis of our statistical data which aims to present the Australian experience with safe work occurrences and highlight the key areas where further attention should be focussed.

We continue to work on a national approach to rail safety investigation and have been holding negotiations with Western Australia and Queensland to complete the process of establishing a unified national system of rail safety investigation.

Resource constraints

As reported last year, our resource situation led us to reduce our workforce by approximately 12 per cent. We have experienced further budgetary restraint this year despite the additional resources provided to undertake the search for MH370. Budget restraints have had a significant effect on our responsiveness and flexibility and continues to affect our capacity to conduct investigations. Our performance statistics for the year show this very clearly, particularly in regard to the timeliness of our investigations. This year, I have incorporated a table in our performance reporting which shows our longitudinal results over the past three years.

Safety priorities

Through our SafetyWatch initiative we maintain a continuing focus on nine safety priorities:

  • flying with reduced visual cues
  • general aviation pilots
  • handling the approach to land
  • data input errors
  • safety around non-controlled aerodromes
  • under-reporting of occurrences
  • safe work on rail
  • marine work practices
  • maritime pilotage.

Outlook for 2015–16

Resources continue to be constrained. It is a simple fact that with fewer resources we can do fewer investigations, or we must constrain the scope of some of the investigations we do undertake. More than ever, we need to choose those accidents or incidents that have the greatest potential to yield the greatest safety benefit. There remains a substantial risk we will miss an important issue. To minimise this risk, we are focussing strongly on analysis of our data and our investigation findings to identify emerging trends. Our short investigations also play an important role in enabling us to take a closer look at accidents and serious incidents which have the potential for more detailed systemic investigation. The importance of the work has not diminished and I am pleased that the Government has reaffirmed the value of our work.

Once again I would like to acknowledge the first class work of our investigators and other staff, and to thank them for their continued commitment to the ATSB. I am also grateful for the continuing attention, support and wise counsel of my fellow Commissioners.

Martin Dolan

Chief Commissioner/CEO

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