The ATSB Annual Report 2017–18 outlines performance against the outcome and program structure in the Infrastructure and Regional Development Portfolio Budget Statements 2017–18.

Chief Commissioner's Review 2017-18

In my second year as Chief Commissioner, the team and I have continued to position the ATSB as a multi-modal, teams-based, world-class transport safety investigation agency. At the start of 2017–18, the Australian Government allocated the ATSB additional funding to address the resourcing challenges encountered in previous years. We have used this funding to put the ATSB on a path of transformation.

We recruited 17 new investigators who are already making an active contribution to transport safety. We are investing significantly in the development of our investigators to position them to be able to disseminate safety findings to industry and the public as quickly as possible. As a team, we have also prioritised the completion of a number of complex investigations, delivering safety outcomes while also freeing up key resources for new investigation priorities. The investment made over the last year will see continued improvement towards the ATSB being able to meet its deliverable targets.

Over the year, we were pleased to bring on board Executive Director Transport Safety, Nat Nagy. Mr Nagy, along with myself and Chief Operating Officer Colin McNamara, constitute the ATSB’s Executive. The Executive are working well with the ATSB’s Commission to build the ATSB up as a world-class investigator for the future. We are fortunate to have the Minister for Infrastructure and Transport reappoint Commissioners Carolyn Walsh, Noel Hart and Chris Manning. The expertise provided by these Commissioners across the aviation, rail and marine transport modes is essential for ensuring we are meeting the interests of our stakeholders with our investigations.

Multi-disciplinary workforce

The ATSB’s greatest resource continues to be its people. We are creating an environment where our employees are empowered. With the multi-disciplinary teams-based approach to our work implemented in 2017–18, we have removed the structural barriers between investigators, researchers and data analysts. The majority of our people are multi-skilling across all these disciplines.

We also have investigators with a background in one particular mode stretching themselves to become involved in investigations from other modes. We are bringing to bear our collective core investigative skills, shared values, passion and drive to improve transport safety.

Building our networks

In 2017–18, we committed to building our networks to deliver our safety messages further. The ATSB was represented at a large number of industry events during the financial year and a number of presentations were provided to stakeholders from the aviation, rail and maritime industries. In May, I presented at Rotortech 2018 on the Sunshine Coast. This provided a platform to launch ‘Don’t Push It, Land It’—a new safety initiative for the helicopter industry, in conjunction with the Australian Helicopter Industry Association and the Civil Aviation Safety Authority. We were also represented by our Executive Director Transport Safety at the RISSB Rail Safety Conference in Sydney. This year I had the honour of being asked by the Royal Aeronautical Society to present the Lawrence Hargrave Memorial Lecture in Melbourne.

In May, I attended the International Transportation Safety Association meeting in Baku, Azerbaijan. This provided a valuable opportunity to exchange information and knowledge with my international counterparts. I was also appointed to the Defence Aviation Safety Council.

We have worked to enhance the mediums through which we communicate. To counter misinformation and provide transparency, we have become more proactive in engaging early with media when there is a transport safety occurrence. We have also been making information more accessible through the use of social media and visual mediums, such as infographics and the production of videos.

Our devotion to making sure that key safety messages are heard is essential for influencing industry and the travelling public towards safe outcomes on the back of our investigative work.


During the year, we completed 25 complex aviation safety investigations and 34 short investigations.

The ATSB released the findings from its second investigation into the ditching of an Israel Aircraft Industries Westwind aircraft (VH-NGA) off Norfolk Island in 2009 (AO‑2009‑072). The release of this report demonstrates the diligence of the ATSB in ensuring that it drives safety forward. Thirty-six safety factors were included in the report, with the key message for flight crew, operators and regulators being that unforecast weather can occur at any aerodrome. There is a need for robust and conservative in‑flight fuel management procedures for passenger-transport flights to remote islands and isolated aerodromes.

Another published report relating to weather was the investigation into a collision with terrain involving an Airbus Helicopters EC 135 T1 (VH-GKK) at Cooranbong, New South Wales in 2015 (AO-2015-131). The safety message from this investigation is that avoiding deteriorating weather conditions requires thorough pre-flight planning. Pressing on into instrument meteorological conditions without a current instrument rating carries a significant risk of encountering reduced visual cues leading to disorientation.

Two reports were published covering pilot interaction with automated technology: a collision with terrain involving a Cessna 172 (VH-ZEW) near Millbrook in Victoria in 2015 (AO-2015-105) and a near collision involving Beech Aircraft Corp B200 (VH-OWN and VH-LQR) at Mount Hotham in Victoria in 2015 (AO-2015-108). Pilots need to have a thorough understanding of all systems on board their aircraft and have the skill to provide redundancy when those systems fail, or their performance is reduced.

In addition to completing some significant investigations, a number were also commenced over the year. The collision with water involving a de Havilland Canada DHC-2 Beaver aircraft (VH-NOO) on the Hawkesbury River in New South Wales on New Year’s Eve drew substantial media attention (AO-2017-118). The ATSB response demonstrated our ‘on-call’ readiness at all times. The preliminary factual report was released on 31 January 2018.


The ATSB completed 13 complex rail safety investigations and three short investigations. Included in these releases is the publication Safe work on track across Australia: Analysis of incident data, 2009–2014 (RI-2014-011). The review
of data showed that incidents while maintenance work was being carried out were predominately a result of errors during the implementation or dissolution stage of providing track protection. Protections were either removed incorrectly or prematurely, or key communication exchanges failed to establish the location of the worksite with respect to approaching rail traffic. Improving the levels of safe working on track continues to be an ATSB SafetyWatch priority.

The derailment of train 3MP5 at Rawlinna, Western Australia in 2016 (RO-2016-005) was significant for demonstrating the risks of approaching safety-critical zones at higher speeds. The publication of a report into a signalling control system irregularity at Ballarat, Victoria in 2016 (RO-2016-011) showcased how critical it is for system designers to ensure that the functionality and performance requirements needed to meet all operational scenarios are incorporated within the system. The ATSB found that the train controller had placed a block on the three sets of points, but these ‘blocks’ were ineffective due to design errors within the train control system.

With Queensland coming on board within the national rail safety system, the ATSB commenced eight investigations into rail occurrences in the state over the 2017–18 year. In recognition of the complementary role the regulator and investigator play in the national rail safety system, the Office of the National Rail Safety Regulator and the ATSB signed a new Memorandum of Understanding (MOU) to set out the roles and relationships of the respective organisations. Under the terms of the MOU, in the coming year the ATSB will look forward to receiving a greater range of occurrences information to assist with data analysis and research.


The ATSB completed four complex marine safety investigations and three short investigations. The published investigations included a loss of propulsion event on the passenger cruise ship Norwegian Star in Bass Strait in February 2017 (MO-2017-003). This investigation highlighted that the operation of newly designed equipment without redundancy increases operational risks. Equipment manufacturers and ship operators must apply extra diligence when designing, installing and operating modified equipment, especially safety-critical equipment.

The ATSB continues to have collisions between trading ships and small vessels reported. A common contributing factor that was present in the investigation into a collision between the container ship Glasgow Express and the fishing vessel Mako in Bass Strait, Victoria in 2017 (MO-2017-007) is the failure to use all available means to accurately appraise a situation and obviate the risk of collision. The ATSB reinforces the importance of a proper lookout by all available means, including radar, to masters, owners, operators and skippers of all vessels.

With the Australian Maritime Safety Authority (AMSA) taking full responsibility for domestic commercial vessels from 1 July 2018, the ATSB invested in seeking to understand the role it can play in the new national maritime safety system. While there is no agreement for an ATSB-funded role, the ATSB committed to a policy to make itself available for major accidents where resources are made available. The ATSB will continue to work with the appropriate Commonwealth and state agencies to clarify its role.

Malaysia Airlines Flight 370—international contribution

On 3 October 2017, the ATSB published its final report into its work coordinating the search for missing Malaysia Airlines Flight 370 (MH370) (AE-2015-054). 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.

With the finalisation of the ATSB’s work, responsibility for MH370 matters was handed over to the Joint Agency Coordination Centre (JACC) in the Department of Infrastructure, Regional Development and Cities.


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. During the year, I will release a ‘Vision 2025’ statement for the ATSB. The statement will explain the ATSB’s vision to ‘drive safety action in a rapidly changing transport environment’.

Over the next few years, the transport sector is expected to see significant changes in technology, including increased automation (or remotely piloted operation), manufacturing efficiencies and enhanced use of big data to predict future hazards. Workforce challenges are also expected, with shortages of key personnel in some sectors and increased movement of operational staff between employers. From the ATSB’s perspective, we also expect to see opportunities to broaden our jurisdiction across transport modes.

The ATSB must be able to maintain its status as a world leader, implementing best practice in transport safety investigation in this changing environment. It is essential that we are positioned to be able to expose the critical safety issues that others cannot and influence the necessary safety action to provide confidence in our transport systems.

The immediate focus in 2018–19 will be to make progress in addressing some of our key performance indicators around the timeliness for completion of reports. I am confident that we can make good progress, particularly following our recent investigator recruitment exercise. The year will be a positive one, with our team committed to making our aviation, rail and marine modes of transport safer.

Greg Hood

Chief Commissioner


Publication Mode
Publication date
Publication type
Publication Number
Annual Report 2017-18