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The ATSB Annual Report 2019–20 outlines performance against the outcome and program structure in the Infrastructure, Regional Development and Cities Portfolio Budget Statements 2019–20.

ATSB Chief Commissioner Greg Hood

In a time of great uncertainty due to the COVID-19 global pandemic, I am proud to report that in 2019–20 the Australian Transport Safety Bureau (ATSB) has been able to continue our focus on improving transport safety through the independent investigation of accidents and incidents, with minimal impact on our productivity and performance.

With many ATSB investigators and operational support staff having come from aviation, rail and marine transport backgrounds, and continuing to maintain those strong industry links, we have great empathy for operators and their respective workforces who are facing an indeterminate future and challenging road to recovery.

Other than the secondment of some staff to Services Australia, we have not been directly involved in the pandemic relief and recovery efforts. However, in support of the transport industry we have continued to apply our safety knowledge and expertise in carefully monitoring the return to operations of safe and reliable transport. 

As an operational agency undertaking an essential service, despite the COVID-19 travel restrictions, the ATSB has and will continue to deploy transport safety investigation teams where and when required across the nation during the course of the pandemic. Further, the ATSB’s ICT infrastructure has successfully supported working from home arrangements for our staff. I have worked hard to ensure our staff know that they are supported and feel connected during periods of home-based work and a period of unprecedented uncertainty.

The ATSB has seen a lessening in the number of transport safety occurrences reported to it in the second half of 2019–20, reflective of decreased activity in the aviation industry in particular, due to the COVID-19 pandemic. In addition, we have worked hard as an organisation to reduce the number of active investigations undertaken over time, as we more effectively manage our resources to ensure improved timeliness of report completion.

Nonetheless, during the summer months of 2019–20 we launched a number of complex investigations into significant transport safety accidents, including:

  • the collision between two freight trains at Jumperkine, Western Australia
  • the collision with terrain of a C-130 Hercules large air tanker near Cooma, New South Wales
  • the derailment of an XPT passenger train at Wallan, Victoria
  • the mid-air collision between two twin-engined training aircraft near Mangalore, Victoria.

Then in early March we launched our investigation into the collision with terrain of a Cessna 404 twin-engine aircraft, with the loss of life of all five on board, near Lockhart River, in far north Queensland.

That long summer of 2019–20 saw the worst bushfire season in Australia’s living memory, which meant a period of high operational tempo for aerial firefighting across Australia. In response to the subsequent Royal Commission into Natural Disaster Arrangements’ request for information, the ATSB produced a safety analysis of aerial firefighting occurrences in Australia, covering the period July 2000 to March 2020. This research report found that estimates of aerial firefighting activity for the 2019–20 bushfire season were around four times higher than other recent bushfire seasons, with more reported occurrences involving aerial firefighting aircraft in Australia in the financial year covering the last bushfire season (between July 2019 and March 2020) than any financial year since July 2000.

The ATSB will continue to examine aviation firefighting safety occurrences with a systemic safety study to commence in 2020–21.

As the COVID-19 pandemic saw a reduction in transport industry activity and transport safety occurrences, in the later months of the year our focus has been on finalising investigations and publishing their final reports. I am pleased to report for 2019–20, we completed and published 47 complex investigations, compared to 34 completed and published complex investigations in 2018–19.

A number of those completed and published complex investigations have led to meaningful improvements in transport safety, and better understandings of transport safety risks. Examples of safety issues raised by ATSB investigations published during 2019–20 concerned upper torso restraints in light aircraft, container ship cargo planning processes, and procedures and guidance for two-driver train operations.

These published investigations, and our new investigations commenced in 2019–20, are consistent with our Minister’s Statement of Expectations, for the period 15 July 2019 to 30 June 2021, which directs us to focus on transport safety as the highest priority, and to give priority to transport safety investigations that have the potential to deliver the greatest public benefit through improvements to transport safety.

These principles guide us in determining which accidents and incidents to investigate, and how best to direct our time and resources, to ensure the best safety outcome for the greatest public benefit. We focus on the public interest where the safety of passengers and workers is concerned, and also on the significant costs to the national economy that can result from an accident.

People and capabilities

It is the skills, professionalism and experience of our people, combined with our highly developed technical expertise and analysis capabilities that enable us to undertake those investigations that have the potential to deliver the greatest public benefit. Right across the agency our staff have broad skillsets, expertise and experience relevant to our role as the nation’s transport safety investigator. And nowhere is that expertise more evident than the ATSB’s governing Commission.

I am very pleased to note that in October 2019, Mr Gary Prosser was appointed to the ATSB Commission. Mr Prosser has 40 years’ experience in the maritime industry, coming from a seagoing career and serving on a wide variety of Australian ships in both the international and domestic trades. More recently, Mr Prosser was the Deputy Chief Executive Officer of the Australian Maritime Safety Authority (AMSA), and he has also served as the Secretary General to the International Organization for Marine Aids to Navigation (IALA).

I am equally pleased to note that Mr Chris Manning was in June 2020 reappointed to the ATSB Commission for a further three years. A former Chief Pilot with Qantas Airways, Mr Manning’s work on the Commission has been exemplary, and we are fortunate to have him with us, working to make transport safer in Australia.

Our Commissioner, Ms Carolyn Walsh also had her tenure extended until September 2020 making her the longest-serving ATSB commissioner.

I would also like to acknowledge and thank Mr Noel Hart for his service to the ATSB Commission and his commitment and passion for improving transport safety since he was first appointed as a Commissioner of the ATSB in July 2009. Mr Hart provided invaluable maritime industry knowledge and experience to countless ATSB investigations.

Also central to the quality of investigations is our ongoing investment in technologies, training and professional development to ensure our investigators have the best available tools and skillsets.

The professional development pathway for our investigators begins with our program of tertiary qualifications the ATSB initiated in partnership with RMIT University in 2019. The inaugural delivery of the Graduate Certificate in Transport Safety Investigation saw 25 participants from both the ATSB and industry gain this coveted tertiary qualification.

The RMIT University partnership will expand to include the development of Graduate Diploma and Masters Programs over time, and is an integral component of our strategy to create a centre of excellence for transport safety investigation in the Asia Pacific region. The ATSB will continue to advance its own safety investigation capabilities through the delivery of these courses, in addition to ensuring that the opportunity exists for industry to do the same.

And we continue to make investments in systems and technologies to ensure our investigators have the best available to effectively undertake their work. Examples include our laser scanning and remotely piloted aircraft systems (RPAS) combined with high accuracy differential GPS data to produce a range of outputs from videos to three-dimensional models of accident sites and vehicles.

Influencing safety action, education and collaboration

Through stakeholder engagement, communication, education and collaboration, the ATSB aims to improve transport safety via influencing safety action. Through our investigations we can identify safety issues but have no powers to make others take safety action. Instead, the ATSB actively engages with stakeholders who are already safety advocates and who may be able to work with us on influencing others to improve safety.

In 2019–20, the ATSB took advantage of a number of key forums and events hosted by industry partners to share priority safety messages and educate key stakeholders as to our role and responsibilities.

In October 2019, we were proud to co-host, alongside the Rail Industry Safety and Standards Board (RISSB) and the Office of the National Rail Safety Regulator (ONRSR), rail safety experts from across the globe at the 29th International Railway Safety Council in Perth.

Also in October, we held our inaugural maritime safety forum, SeaSafe 2019. Following on from the success of our FlySafe 2019 and RailSafe 2019 safety forums delivered in 2018–19, SeaSafe 2019 aligned with the two-day Pacific 2019 International Maritime Exposition in Sydney in order to maximise participation from key stakeholders.

In May 2020, we had planned to host the annual forum of the International Transportation Safety Association (ITSA), for which I am currently the Chair. ITSA is the international network of heads of agencies of independent transport safety investigation authorities from 17 nations, covering aviation, marine, rail and road transport, as well as pipelines and underground infrastructure. This year’s forum, which was to have been held in Sydney, was deferred due to the COVID-19 pandemic.

The mission of ITSA is to improve transport safety in each member country by learning from the experiences of others. It is my hope that that mission can be furthered with our next forum some time in 2021, whether that is held in person in Sydney, or virtually.

And while COVID-19 travel restrictions have placed many conferences and forums on hold, the ATSB has enthusiastically embraced virtual conferences and events to share our safety messages.

Sharing of resources and knowledge is central to our collaboration with our colleagues at the Defence Flight Safety Bureau (DFSB). In January, we were able to exercise the provisions of our Memorandum of Understanding (MoU) with DFSB when they seconded a representative with expertise in the C-130 aircraft to join our investigation team working on the C-130 large air tanker accident.  

The ATSB also has in place memoranda of understanding with a number of industry associations that are in a position to reach out to their members with messaging that is tailored to their working environment.

Another example of cooperation was in November, when the ATSB’s communications team hosted media and communications representatives from the AMSA, the Civil Aviation Safety Authority (CASA), Airservices Australia, and the then Department of Infrastructure, Transport, Cities and Regional Development for the first in a series of regular meetings to share details of communications, media and safety promotion activities across the broader group.

This forum will allow the portfolio agencies to work together on promoting and sharing safety issues and education campaigns, such as the ATSB’s ‘Don’t Push it, Don’t Go’ campaign, launched in September 2019 to raise awareness of the dangers of visual flight rules (VFR) for pilots flying into instrument meteorological conditions (IMC).


In 2020–21, we will be aligning a new set of performance measures with our Vision 2030 statement. These have been designed to demonstrate our effectiveness against our mission to:

Improve transport safety for the greatest public benefit through our independent investigations and influencing safety action.

Through the revised performance criteria, we are focused on being able to demonstrate the safety action taken in response to our investigations, ensuring that our findings are defendable and timely, and that our resources are being used efficiently.

I intend to publicly release our Vision 2030 statement during 2020–21 at an appropriate time, mindful of and sensitive to the changes occurring within the transport industry.

Another key focus for our agency in 2020–21 will be the replacement of our investigation information management system. This is a significant and essential project utilising cloud technologies and software that will service the ATSB’s investigation information management needs for many years. Investigators will be able to access data and upload evidence to the new system anywhere on any device, while the removal of labour-intensive processes promises to improve our productivity.

From bushfires to a global pandemic, 2019–20 has been a year of unprecedented challenge. I am proud of the ATSB’s staff who have, time and time again, proven themselves resilient and adaptable during this period of uncertainty. Like all Australians, ATSB staff across the nation have had to adapt to changing circumstances during this pandemic. At a professional level they have remained committed to their work, whether this be from the office, home or deploying to transport accident sites across state borders.

Australia’s aviation, rail and marine industries are safer for their efforts.

Greg Hood

Chief Commissioner


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Annual Report 2019-20