The ATSB Annual Report 2015–16 outlines performance against the outcome and program structure in the 2015–16 Infrastructure and Regional Development Portfolio Budget Statements.

Chief Commissioner's review 2015-15 - Greg Hood

Chief Commissioner’s review 2015–16

This was the ATSB’s seventh year as a fully independent body within the Infrastructure and Regional Development portfolio. 2015–16 also marked the final year of Martin Dolan’s tenure as the ATSB’s Chief Commissioner. While Martin’s real and significant contributions to improving transport safety have been widely acknowledged, it was his passion, energy and commitment to maintaining the ATSB’s reputation as a world-leading safety investigation body that will be remembered as his most enduring qualities.

Ongoing challenges

As foreshadowed through the ATSB’s 2015–16 Corporate Plan, the ATSB entered this reporting period faced with an operating environment of continuing growth in, and progressive changes to, the composition of the aviation, rail and marine transport sectors. In contrast, the ATSB has continued to experience successive reductions to its base appropriations with further reductions projected over its forward estimates. To manage these fiscal circumstances, the ATSB has reduced its core staffing profile, including specialist investigators, by approximately 25 per cent from when it was established as an independent statutory authority in July 2009.

Notwithstanding these challenges, the ATSB was able to complete a range of significant and comprehensive investigation reports during 2015–16, in addition to supporting the secondment of a number of specialist staff to the continuing search for the missing Malaysia Airlines Flight MH370 and the reopened investigation into the Norfolk Island ditching accident.


When reflecting on the agency’s overall performance against its key deliverables and performance indicators, the ATSB has continued to meet its targets in terms of the quality and quantity of investigation reports completed and published per year. However, it is evident the ATSB has not been able to complete these reports within the published prescribed timeframes.

In relation to other key functions and broader portfolio responsibilities, the ATSB continues to maintain a capacity to record, analyse and research safety data and produce timely reports on safety trends and other research publications. Given its resource constraints, the ATSB has limited capacity to foster safety awareness, knowledge and action through safety education and has relied heavily on social media to disseminate key messages.

The ATSB has continued its transition to becoming the national rail safety investigator, as established through the Council of Australian Governments Intergovernmental Agreement on Rail Safety Regulation and Investigation Reform. In addition to the Defined Interstate Rail Network, the ATSB now has primary responsibility for investigating rail safety accidents and incidents on regional networks and metropolitan passenger networks in all states and territories other than Queensland.

Similarly, the ATSB has continued an active program of regional engagement with other transport safety agencies within the Asia Pacific region. Consistent with the approved projects and associated program funding agreements, the ATSB has undertaken a range of capacity building activities including investigator training and mentoring, policy and guidance development, and establishing compliance with international standards.

The search for Malaysia Airlines Flight MH370

Since May 2014, at the request of the Malaysian Government, the ATSB has been leading the search operations for missing Malaysia Airlines Flight MH370, in the Southern Indian Ocean. The search for the Boeing 777 aircraft remains a major priority for the ATSB.

During the year, the operational search faced a number of significant challenges, including lost and subsequently recovered underwater electronic search equipment, medical evacuation of unwell crew and prolonged severe weather.

In December 2015, the search identified the wreck of a ship, likely to be a steel or iron vessel, dating from the turn of the 19th century. Importantly, the discovery of the shipwreck shows how the methods and technology used in the search will effectively detect and identify the missing Boeing 777 aircraft.

ATSB technical specialists also examined a number of items of aircraft debris, which were discovered on the shorelines of western Indian Ocean states. Several pieces were recovered and examined, one by the French authorities and the remainder by the ATSB. Other parts are being retrieved by the Malaysian Investigation Team for further assessment.

We continue to work with our Minister and our Malaysian and Chinese counterparts to ensure that they are kept appraised of the search progress and to enable joint decisions to be made when required.


During the year we completed 44 aviation safety investigations and 90 short factual investigations. One significant aviation investigation involved the landing below the minima of two Boeing 737 aircraft at Mildura Airport, Victoria due to fog conditions (AO-2013-100). Both aircraft were on scheduled flights when, on nearing Adelaide Airport, fog precluded their landing.

ATSB has recommended that Airservices Australia work in collaboration with the Bureau of Meteorology to instigate a system change to reinstate the alerting function of special weather reports currently not available through an Automatic Broadcast Service.

In parallel with this occurrence investigation, the ATSB commenced a research investigation to examine the reliability of aviation weather forecasts. This research will analyse Bureau of Meteorology weather data for major Australian airports.

Other significant aviation investigations have led to improvements in the inspection method for detecting cracks in the wing attachment fittings in M18 Dromader aircraft and the removal of at-risk lateral tie rods from DH82 and DH82A Tiger Moth aircraft, with worldwide implications for this aircraft type. The ATSB also concluded its involvement as an accredited representative to the investigation by the Dutch Safety Board of the crash of Malaysia Airlines Flight MH17 in Hrabove, Ukraine on 17 July 2014.


The ATSB completed seven marine safety investigations in 2015–16. Significantly, two of the occurrences we investigated—an engine room fire on board bulk carrier Marigold and a man overboard fatality from Cape Splendor, both at Port Hedland, Western Australia—highlight the importance of investigating incidents and accidents to improve safe marine work practices.

ATSB urges the maritime industry to give heightened attention to marine work practices. As these incidents have shown, it is essential that employees implement good risk management and safety practices to prevent injury and loss of life.


During the year, the ATSB completed 19 rail safety investigations. The most significant of these involved rail collisions, derailments and a passenger fatality at Heyington Railway Station in Victoria.

We continue to investigate occurrences where breaches of safe work practices place maintenance crews and operators at risk. The ATSB initiated a safety issue investigation into safe work on track in 2014, which is now nearing completion.

As part of this investigation, we have collected and analysed over 12,000 records, categorised under the Safework Rule Procedure Breach guidelines, between June 2009 and June 2014.

Of these, approximately 15 per cent were assessed by the ATSB as being work on track-related occurrences. Preliminary analysis indicates that the majority of these occurrences can be traced to protection types being insufficient or incorrect, protection location being incorrectly positioned, protections being incorrectly removed and worksite location being incorrectly identified.

On 2 November 2015, Western Australia joined the national rail safety scheme and the ATSB now investigates accidents and incidents on Western Australia’s metropolitan and regional passenger and freight rail networks.

This new focus in Western Australia will result in more investigations conducted across a greater range of safety matters. It also means that the ATSB is the mandatory notification point for all Category-A occurrences within Western Australia.

We are continuing our negotiations with Queensland to complete the process of establishing a unified national system of rail safety investigation.

Outlook for 2016–17

As the newly appointed Chief Commissioner on 1 July 2016, I am proud to lead a world-class and lean transport safety investigator. But I am keen to reshape how we commit our limited resources to improve safety for the travelling public.

We will continue investigating the majority of accidents and serious incidents involving the travelling public. This is where there is the greatest risk of loss of life and the greatest likelihood of finding significant safety issues that lead to important safety actions.

We will, however, seek to improve our efficiency by becoming more data-driven. The ATSB has one of the richest national information datasets of all safety-related occurrences in aviation as well as accidents and significant safety occurrences in the rail and marine sectors.

We use this data to identify safety trends in the aviation, rail and marine sectors but I would like to interrogate the data more actively. In so doing, we will be able to more selectively allocate our limited resources to investigating those accidents and incidents that that have the greatest potential for improving safety. If there is no obvious public safety benefit to investigating an accident, the ATSB is less likely to conduct a complex, resource-intensive investigation.

The ATSB endeavours to investigate all fatal accidents involving VH-registered powered aircraft subject to the potential transport safety learnings and resource availability. But we will need to carefully consider the resources we allocate to investigations into general aviation fatal accidents and constrain the scope of investigations into non-fatal accidents in this sector.

Safety education is key to addressing accidents and incidents that recur in general aviation. There are diminished safety benefits from investigating occurrences where there are obvious contributing factors, such as unauthorised low-level flying or flying visually into poor weather. Instead, educating pilots on the dangers of high-risk activity is where we will refocus our efforts, with an emphasis on using social media.

There are many challenges facing us in the future. Technology is already having an influence on our work. The use of remotely piloted aircraft is increasing significantly—pizza delivery by drone is reportedly imminent.

How ATSB investigates and monitors the safety of an increasing number of low-cost carriers operating within Australia will require careful consideration.

The ATSB will accumulate and interrogate its data rigorously to determine if there are indeed any systemic safety issues that affect the safety of the travelling public and others in the industry.

In the meantime, we will work with the marine, rail and aviation industries to highlight the safety concerns already identified from our occurrence data and investigation findings.

While the ATSB faces significant challenges, I am confident that the professionalism and capability of our people will ensure the ATSB remains a world-leading transport safety investigator.

Greg Hood

Chief Commissioner/CEO

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