The ATSB Annual Report 2016–17 outlines performance against the outcome and program structure in the Infrastructure and Regional Development Portfolio Budget Statements 2016–17.

Chief Commissioner's Review 2016-17 - Greg Hood

Appointed Chief Commissioner on 1 July 2016, I was honoured to be provided the opportunity to lead a world-class transport safety investigation agency. As the accountable authority, I was acutely aware that the ATSB’s primary function is to improve transport safety with priority given to delivering the best safety outcomes for the travelling public. Having worked in other agencies within the transport portfolio for an extended period of time, I was also cognisant of the agency’s operational environment and the associated challenges. It was within this context that I determined the ATSB needed to be repositioned to face these challenges with courage and determination.

Evolving our capabilities and capacity

The ATSB has undertaken a significant transformation program designed to enable better resource allocation and utilisation across the agency. A number of change imperatives underpinned this program which provided the impetus to refine our business practices and expand our deliverables.

In demonstrating increased effectiveness, we have become more selective in how we allocate resources towards investigating those accidents and serious incidents that have the greatest potential for safety learnings and enhancement. Concurrently, we have expanded our capacity to improve transport safety outside of these traditional investigations, through safety issue investigations, greater interaction with operators and regulators, with data and other intelligence in our possession, and through amplified communications, safety education and promotion.

Key success factors

The ATSB’s greatest resource continues to be “its people” and while there have been changes within our organisational structure—most notably the introduction of multi-disciplined/modal investigator teams—we are well on the way to creating an environment where our employees are empowered. Our people are provided greater opportunities to bring to bear their collective core investigative skills, shared values, passion and drive to improve transport safety. This equally applies to our dedicated and professional operational support staff.

Through the Government’s recent 2017–18 Budget measure “improving transport safety”, the ATSB has been able to re-establish a sound financial position over the next four years. This increase in funding will enable the ATSB to replenish its workforce and re-profile its capital investment strategies to meet its projected needs in essential technical equipment, data warehousing requirements and core enterprise systems.

Core business

The ATSB has committed considerable resources and time to re-engineering its operational model over 2016–17. We did so whilst taking appropriate measures to ensure this did not impact our ability to conduct core business activities, as demonstrated through the range of significant and comprehensive investigations that were either commenced or completed during the financial year.

In relation to other broader functions, the ATSB has completed 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. This milestone coincides with the Queensland Parliament’s agreement to join the national rail safety scheme from 30 June 2017.

Internationally, we have continued an active program of regional engagement with other transport safety agencies within the Asia–Pacific region—most notably with our Indonesian and Papua New Guinean counterparts.


During the year, we completed 39 complex aviation safety investigations and 108 short factual investigations.

This year a second interim report was released into the in-flight pitch disconnect of a Virgin Australia Regional Airlines ATR 72 aircraft that occurred about 50 km west-southwest of Sydney Airport, NSW. That report identified a safety issue concerning activation of the aircraft’s pitch uncoupling mechanism with world-wide implications. The ATSB has issued safety recommendations to the aircraft manufacturer, the Civil Aviation Safety Authority (CASA) and the European Aviation Safety Agency to take action to ensure that the aircraft can safely withstand the loads resulting from a pitch disconnect.

A report was also released for an investigation involving the collision with terrain of a parachuting aircraft at Caboolture Airfield, Queensland that fatally injured the five occupants. The ATSB identified that the aircraft aerodynamically stalled at a height from which it was too low to recover control prior to collision with terrain. As a result of that investigation, the ATSB recommended that CASA introduce risk controls to provide increased assurance of aircraft serviceability, pilot competence and adequate regulatory oversight. The ATSB also recommended that CASA work in collaboration with the Australian Parachute Federation to increase the usage of dual point passenger restraints in parachuting aircraft.

Another significant aviation investigation included a traffic management occurrence involving a Jetstar Airbus A320 and a Beech Aircraft Corporation BE-76 Duchess at Ballina/Byron Gateway Airport, NSW. That investigation identified a safety issue relating to the available traffic advisory facilities. The introduction of a certified air/ground radio service to provide weather services and traffic information at the airport in March 2017 is expected to address that safety issue.

The ATSB also released the first research report on Remotely Piloted Aircraft Systems (RPAS). This report showed that there has been a steep rise in the number of RPAS certificate holders in 2016, coinciding with a similar rise in safety occurrences. About half of the 180 occurrences from the past five years related to near encounters with manned aircraft. Of these, 60 per cent were in 2016. Fortunately, there have been no collisions in Australia between RPAS and manned aircraft. The potential consequences of a collision remain uncertain given the limited research available. However, RPAS are an emerging risk that require close monitoring as the number of these aircraft continues to grow.


During the year, the ATSB completed 16 rail safety investigations. These involved collisions, derailments and failures of safe work practices. Of significance were a level crossing collision between a freight train and a road-train truck near Narromine, NSW, (RO-2015-016) and the derailment of a freight train carrying dangerous goods near Julia Creek, Queensland (RO-2015-028).

The ATSB also continues its focus on occurrences where breaches of safe work practices may place maintenance crews and operators at risk. An investigation has commenced into a fatal collision between a track worker and passenger train near Petrie, Queensland which occurred on 29 May 2017 (RO-2017-003). In addition, our safety issues investigation into safe work on track is nearing completion and will go through a period of public consultation in preparation for final release before the end of 2017.


The ATSB completed five marine safety investigations in 2016–17. One significant investigation involved a crew member fatality on board the offshore support vessel Skandi Pacific, off the West Australia coast (MO-2015-005). The crew member was crushed while attempting to secure containers during worsening weather conditions.

The investigation complements an ATSB SafetyWatch priority focusing on marine work practices and resulted in a Safety Advisory Notice being issued to highlight the risks posed by open stern vessels in the industry.

The report into the breakaway of the Spirit of Tasmania II from its mooring at Station Pier in Melbourne, Victoria (MO-2016-001) highlighted that all ships, especially those with high windage, are prone to breaking away from moorings during short-term events such as thunderstorms and squalls. The risks this presents to ships with large numbers of people on board means that weather monitoring, mooring systems and procedures need to be regularly checked and verified for changing weather conditions.

Malaysia Airlines Flight 370—international contribution

In January 2017, a Joint Communiqué issued by the Tripartite Governments (Malaysia, Australia, and the People’s Republic of China) formally announced the suspension of the underwater search for missing Malaysia Airlines Flight 370 (MH370) following completion of the 120,000 km2 search area. Should credible new information emerge that can be used to identify the specific location of the aircraft, consideration will be given to determining next steps.

Whilst search operations have been suspended, search area analysis and activities have continued, and an end of search report was released in the third quarter of 2017.

The search for MH370 has been a complex international program, the largest and most complex search for a missing aircraft in history. The effort of the dedicated ATSB and associated personnel involved in the search is a testament to their ingenuity, adaptability and resilience. Consistent with Government policy and direction, the ATSB will continue to provide a supporting role to Malaysia as the country responsible for the investigation into the disappearance of MH370.

Outlook for 2017–18

The ATSB will continue to perform its primary function of “improving transport safety” in an operating environment of continuing growth and change in the aviation, rail and marine transport industries.

In recognising these environmental challenges, the ATSB will adopt and implement a range of strategies designed to further increase its overall efficiency and effectiveness.

Selective investigations

The ATSB will refine its methodologies in selecting the accidents and incidents it investigates, recognising its finite resources, differences in jurisdiction across the modes, and its particular focus on the safety of the travelling public.

Data driven

To position the ATSB to become more proactive in its identification of safety issues, we will continue to build our capability to source data nationally on aviation, rail and marine transport safety occurrences and events, and use that data to identify and communicate safety risks and emerging trends.

We will also deliver a program of safety research and analysis that draws on the results of investigations and the interrogation of safety occurrence datasets.

Stakeholder engagement

To encourage greater safety action, the ATSB will enhance stakeholder relationships, with a particular focus on ensuring a strong culture of reporting safety matters, and through transparent arrangements for the appropriate sharing and use of safety information.

Focused communications

To ensure the targeted delivery of its safety messages, the ATSB will undertake safety communication and education with an emphasis on identifying priority areas where safety risk can be reduced.

We will also increase public awareness of the ATSB’s safety activities by developing a broader range of communication and education products and pursuing their delivery to transport industries and the travelling public through media that interact with a variety of stakeholders.

Workforce capabilities

To enhance its workforce capability the ATSB will complete the implementation of its organisational change program, embedding a multi-discipline teams-based approach to investigations, with the objective of enhancing the agency’s efficiency and effectiveness.

We will expand our resource base through attracting, retaining and developing professional staff as well as developing networks with skilled professionals who the ATSB can work with to fulfil its transport safety functions.

Expanding jurisdictions

While the ATSB has a broad jurisdiction in aviation, there is further work to be done as part of the national rail and marine safety reforms. The ATSB will examine how to best address some of the issues surrounding the independent investigation of serious incidents and accidents in the domestic commercial vessel (DCV) sector consistent with any direction as agreed by governments.

These strategies, the associated deliverables and performance indicators (specifically our commitment to improving the timeliness of our outputs), are detailed and presented in the ATSB’s Corporate Plan 2017–18, published on 31 August 2017.

The 2017–18 year will be a positive and exciting period for the ATSB, and I remain confident that the continued professionalism and capability of our people will ensure the ATSB remains a world-leading transport safety investigation agency.

Greg Hood

Chief Commissioner/CEO

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