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The ATSB Annual Report 2018–19 outlines performance against the outcome and program structure in the Infrastructure, Regional Development and Cities Portfolio Budget Statements 2018–19.

Chief Commissioner's Review 2018-19

In 2018–19, the ATSB continued to make a significant contribution to transport safety in Australia, thanks to the release of several substantial and high-profile investigation reports which contained valuable safety learnings for the aviation, rail and marine transport modes. During the year, we also entered into a strategic partnership with the Royal Melbourne Institute of Technology (RMIT) University, continued with our program of work to further improve our operational efficiency and effectiveness, and implemented an initiative to increase the number of Memoranda of Understandings (MOU) with transport industry associations.

There was much attention on the agency in September 2018 with the publication of the final report from our investigation into a King Air aircraft’s collision with a building in a retail precinct at Melbourne’s Essendon Airport in 2017 (AO-2017-024).

The investigation found the aircraft’s rudder trim was set incorrectly for take-off, resulting in a loss of directional control. The investigation drew upon the ATSB’s world-leading human factors capabilities, which resulted in safety messaging around the use of checklists as an essential tool for overcoming limitations with pilot memory and ensuring action items are completed in sequence without omission. This messaging highlights the ATSB’s approach to safety investigation, which is to ensure that all the lessons can be learnt to help stop accidents in the future.

On an international level, the ATSB’s contribution to safety was exemplified by the release of our final report from the investigation into a serious incident involving an ATR 72 turboprop airliner, which experienced an inadvertent pitch disconnect following an in-flight upset. This resulted in serious structural damage to the aircraft’s horizontal tailplane (AO-2014-032). The investigation into this complex event identified a number of safety factors, including some in relation to the continuing airworthiness of the aircraft, and aircraft certification standards.

As a consequence, the ATSB issued Safety Recommendations to the European Union Aviation Safety Agency to review the current design standards in consideration of the effect that dual pilot control inputs may have on the safe operation of an aircraft.

The ATSB is tasked with using its resources to improve transport safety for the greatest public benefit. We do this through systemic safety investigations that can lead to wide-reaching safety actions, thanks to our highly developed technical expertise and investigation analysis capabilities. I am proud of our capabilities and our program of continual improvement to best deliver transport safety outcomes.

Those capabilities were demonstrated when, during the year, the ATSB sponsored one of the premier psychology, human factors and crew resource management symposiums in the Asia–Pacific region. The ATSB also facilitated additional human factors training courses, adding to the more than 40 courses we have conducted since 2000 to educate those in a position to influence safety.

Partnership with Royal Melbourne Institute of Technology (RMIT) University

The ATSB is focused on ensuring its own people have the highest investigative capabilities and in educating others to achieve the same. If the public trusts that investigators, regulators and operators are identifying and managing safety risks, then there is confidence in safety of the transport system. A significant achievement that I recognise as realising this objective is the partnership entered into this year between the ATSB and RMIT University.

This partnership is part of a vision to create a centre of excellence in the field of accident investigation and transport safety in the Asia–Pacific region. Industries in Australia, throughout the Asia–Pacific and around the world are now able to obtain ATSB-sponsored qualifications in transport safety investigation. The partnership expects to extend to offering a Master’s-level qualification, as well as facilitating transport safety related research.

The first intake of students occurred on 1 July 2019 to study for a Graduate Certificate in Transport Safety Investigation. In 2020, a Diploma in Transport Safety Investigation will be offered before evolving into a Master’s program. Students will gain access to the best insights into the fundamentals of accident investigation, from attending an accident scene and gathering evidence, through to identifying human and other factors that contributed to an accident, investigation analysis and technical report writing.

Enhancing our efficiency

The ATSB is undertaking a program of work to enhance its operational efficiency and effectiveness. The ATSB’s interest is in making the greatest possible contribution to transport safety across the aviation, rail and marine modes of transport with its available resourcing. In particular, we are striving to make sure that our investigation reports are delivered in a timely manner.

During 2018–19, we benchmarked our performance against similar accident investigation agencies overseas. I am pleased to report that our performance is comparable with a number of internationally respected agencies. The median length of time we take to complete an investigation is slightly higher by comparison, but the ATSB is completing more per investigator than some of its comparators. We recently introduced amended key performance indicators to reflect the time it takes to complete complex investigations that look at in-depth systemic factors.

The Australian National Audit Office (ANAO) also audited our operational efficiency during the year. The ANAO found the ATSB has established key elements of an overall framework to promote efficient investigation processes. The ANAO also found that our efficiency had been declining with its use of resources, but acknowledged a number of actions that had already been taken by the ATSB to make improvements, including formalising aspects of its program-managed approach to investigations.

Our continued efficiency improvements will be supported by the large cohort of 17 new transport safety investigators who commenced with us in 2018. After completing their training and gaining further investigation experience, these recruits will take on higher levels of responsibility within the ATSB’s teams-based approach to investigation.

Building our networks

The ATSB recognises the value of being able to call upon the highest levels of expertise to best identify safety issues, and to that end, in 2018–19 we embarked upon an initiative to enter into Memoranda of Understandings (MOU) with transport industry associations. MOUs have now been signed with the Australian Federation of Air Pilots, the Australian and International Air Pilots Association, the Australian Licenced Aircraft Engineers Association, the Australian Association for Unmanned Systems, the Australian Certified Unmanned Aerial Vehicle Operators, Civil Air, and the Human Intervention Motivation Study Australia Advisory Group.

The ATSB will seek to further its reach by signing additional MOUs with industry associations and activating those relationships in 2019–20.

We are also deepening our partnership with the Defence Flight Safety Bureau (DFSB), which performs an equivalent role to us for Defence aviation. Both organisations are committed to investigating accidents and incidents, and analysing occurrence data under the ‘no-blame’ philosophy, with the sole aim of preventing recurrences. Under our MOU, the organisations can conduct joint investigations and participate in each other’s investigations. The relationship and knowledge sharing was strengthened during the year through a secondment of a DFSB investigator, who brought further human factors expertise to the ATSB.

Communicating with influence

The ATSB actively works to influence safety well beyond the publication of investigation reports. This year we held our inaugural FlySafe and RailSafe safety forums, while our SeaSafe marine safety forum will be held in 2019–20. These forums target safety messaging to receptive audiences from across the modes with the expectation that those audiences will share the safety messages with their industry-based colleagues. We have participated in a number of other industry-led safety conferences with this intent.

We have been active online using our website as an engaging information portal, as well as using our social media channels to publish information that is relevant to our stakeholders. In June, we published a video targeting emergency personnel on the potential dangers of inactivated rocket-deployed parachute systems on aircraft. The video has been viewed more than 2,600 times on YouTube, and more than 15,000 times on Facebook. We are a modern investigation agency that knows how to harness the available and emerging communication mediums to influence safety action.

We are focused on delivering the right content to traditional media, too. We have our own dedicated media studio for producing video and audio content for television and radio broadcasts. Conscious of the need to remember those who can inspire us to innovate, our studio is named after Macarthur Job OAM. ‘Mac’ was a pioneer of aviation safety messaging in Australia, editing the principal safety promotion publication of the Department of Civil Aviation’s Air Safety Investigation Branch – the Aviation Safety Digest. Known as the ‘crash comic’, we have further preserved this history by making the 150 editions of the digest (spanning 1953 to 1991) available online through the ATSB’s website.


During the year, we completed 32 complex aviation safety investigations and 28 short investigations.

In addition to the aviation accidents previously highlighted, other significant aviation investigation reports released in 2018–19 include a runway excursion at Darwin Airport involving a Boeing 737 aircraft in December 2016 (AO-2016-166); a collision with terrain involving a Diamond DA40 aircraft near Southport, Queensland in September 2017 (AO-2017-096); and an in-flight upset involving a Boeing 747-400 aircraft near Hong Kong Airport in April 2017 (AO-2017-044).

The Darwin runway excursion resulted from factors that included a small increase in crosswind that led to a significant deviation of the aircraft from the runway centreline at a critical time during the final approach. The investigation highlighted the challenges of landing in darkness and poor weather conditions when landing on wide runways that lack centreline lighting. The operator and Darwin Airport have taken action to provide flight crews with information about the specific risks of approaches at the airport, while a safety recommendation made to the International Civil Aviation Organization has been referred to that body’s Aerodrome Design and Operations Panel for further study.

The collision with terrain of a Diamond DA40 aircraft near Southport resulted in fatal injuries to the instructor and student pilot on board. The aircraft entered a developed spin during manoeuvres consistent with advanced stall recovery training, which likely included intentional incipient spins. The spin continued until the aircraft collided with terrain. Although the investigation could not fully establish the reasons for the accident, the investigation identified varying interpretations of an ‘incipient spin’. The ATSB advised that operators and pilots should clarify with manufacturers the extent to which the early stages of a spin are permissible and ensure aircraft are always operated in accordance with limitations.

The in-flight upset of a Boeing 747 aircraft near Hong Kong resulted from factors that included the aircraft’s aerodynamic stall warning stick shaker activating a number of times and the aircraft experiencing multiple oscillations of pitch angle and vertical acceleration. The safety messaging from this investigation covered the need for comprehensive theory and practical training to ensure flight crews have a complete understanding of aircraft systems and they maintain effective handling skills. The training should provide flight crews with the knowledge to correctly configure the aircraft’s automatic flight systems and manual handling skills to respond adequately to in-flight upsets.


The ATSB completed seven complex rail safety investigations and two short investigations in 2018–19. Included in these releases is the ATSB’s investigation into the derailment of a coal train near Oakey in Queensland in July 2017 (RO-2017-007). It was found to be highly likely the underframe of a heavy road vehicle collided with rail infrastructure at a level crossing. Rail lines were displaced, causing the derailment and destroying about 300 metres of rail infrastructure. The accident highlights how vitally important it is for a driver in a road incident at a level crossing to report any damage and for rail infrastructure managers to ensure crossings are subject to regular and effective inspection.

We released our report from an investigation into another derailment involving an ore train near Walla in Western Australia in December 2015 (RO-2015-023). The derailment occurred due to a broken rail. A fracture of the rail was probably initiated by the rapid growth of a detectable, yet unidentified, fatigue-related defect. It is important that track maintenance and infrastructure fault detection is of a high standard to avoid similar occurrences.

A further derailment investigation involved a freight train near Dry Creek, South Australia in July 2017 (RO-2017-008). There had been a break in the section of track that was precipitated by a defect in the rail introduced in the manufacturing process 90 years ago. The rail break was not visually obvious, and when the freight train passed over it, the last three wagons derailed. The safety message in this accident was around the inspection of rail infrastructure. If an inspection cannot test or can only partly test rails, maintenance personnel must report the shortfall to highlight operational risk and the requirement for a timely supplementary examination.


The ATSB completed five complex marine safety investigations and four short investigations. The published reports included an investigation into a fall from height and serious injuries to crew members on board the Shanghai Spirit near Port Alma, Queensland in January 2017 (MO-2017-001). A mobile scaffold tower was used to conduct routine painting and touch-up work in the cargo holds. Two crew members conducted the work from the upper tiers and remained unsecured when the scaffolding was moved. The tower became unbalanced and toppled forward onto the deck. The safety message highlighted the importance of adhering to procedures that assure safety, as well as the value of effective supervision.

We released our report from the grounding of the Australian Border Force cutter Roebuck Bay on Henry Reef in the Great Barrier Reef in September 2017 (MO-2017-009). The vessel’s route plan had been amended during the passage planning process, resulting in the route being inadvertently plotted across Henry Reef. The cutter’s electronic chart display and information system (ECDIS) identified the reef as a danger to the planned route. However, the vessel’s officers did not identify the danger, either visually or using the ECDIS. The investigation highlighted that the safe and effective use of ECDIS as the primary means of navigation depends on the mariner being thoroughly familiar with the operation, functionality, capabilities and limitations of the specific equipment in use on board their vessel.

The report for the investigation into contact with a wharf by the vessel Madang Coast in Townsville, Queensland in November 2015 (MO-2015-007) was also released. As the Madang Coast moved alongside the wharf, the forward spring line slipped and could not be used during the manoeuvre, as the distance from the stern to the wharf was too far for the aft mooring party to throw any heaving lines ashore. The stern’s movement away from the wharf continued, making contact with another ship, while the bow made contact with the wharf. In this case, the risk management processes were not sufficiently mature nor resilient enough to effectively identify and mitigate risks in pilotage services. The investigation highlights the value of a safety management system that includes effective risk management processes.


Appointed as the Chair of the International Transportation Safety Association (ITSA) in 2019, I will host an ITSA forum in Sydney in 2020. ITSA is a network of the heads of independent safety investigation authorities from around the world. The forum is valuable for sharing safety information and pursuing best practices in investigations. The ATSB will be seeking to continue to benchmark its performance against its peers to ensure that we are delivering optimal outcomes for transport safety in Australia.

Before ITSA, I will be releasing the ATSB’s ‘Vision 2025’ statement. The ATSB’s vision is to ‘stop accidents’, with a mission to ‘drive safety action in a rapidly changing transport environment.’ Vision 2025 is aspirational, sharpening the agency’s focus when conducting investigations, while the mission recognises the transformational nature of the transport operating environment in which investigations are being conducted, and our intention is to influence safety outcomes in that environment.

The vision statement will reflect elements of the Minister’s new Statement of Expectations, issued on 15 July 2019. This includes the need to give priority to transport safety investigations that will deliver the greatest public benefit through improvements to transport safety. Focusing on the public benefit means that the ATSB will have regard for factors that include the potential to save lives, as well as preventing serious adverse economic impacts that result from accidents. There are costs that come with providing safe transport systems, but the cost of an accident can be much higher.

I will also ensure the ATSB pays close attention to the government inquiries related to transport reforms. Two in particular have the potential to result in jurisdictional changes for the ATSB if there are any recommendations resulting in policy change. The Productivity Commission’s inquiry into National Transport Regulatory Reform is looking at the impacts of the rail, marine and road heavy vehicle changes that came out of intergovernmental agreements from 2011 to move the industries towards single national jurisdictions. The Australian Government Review of National Road Safety Governance is examining how to bring down the number of road deaths and serious injuries. Consistent with the Minister’s Statement of Expectations, the ATSB is providing input into these reviews.

I am positive about the agency and the role we will play in improving transport safety going forward. The ATSB has been through significant organisational change over the last few years, all directed towards enhancing our productivity and establishing a shared vision. The ATSB’s staff are dedicated, hard-working experts in their field. Their contribution to safety is highly valued and, with their support, I intend to ensure they are empowered and enabled to make this contribution well into the future.

Greg Hood

Chief Commissioner


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Annual Report 2018-19
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