The ATSB Annual Report 2020–21 outlines performance against the outcome and program structure in the Department of Infrastructure, Transport, Regional Development and Communications Portfolio Budget Statements 2020–21

View on Australian Government Transparency portal

Chief Commissioner's review 2020–21

ATSB Chief Commissioner Angus Mitchell

I am pleased to deliver this annual report for the Australian Transport Safety Bureau (ATSB), my first as Chief Commissioner and Chief Executive Officer.

While continuing to navigate the challenges of the COVID-19 pandemic, 2020–21 saw the ATSB commence, progress and complete a series of complex transport safety investigations; continue to deploy to transport accident sites; develop and implement a new core enterprise investigation information management system; and implement key elements of our strategic property plan.

For this sustained performance in a complex operational environment, I would like to acknowledge the leadership and service of my predecessor, Mr Greg Hood, who retired on 30 June on the completion of his five-year term as Chief Commissioner and Chief Executive Officer.

Mr Hood drove an innovation and transformation agenda at the ATSB, which saw the introduction of world-leading practices like a multi-modal teams approach to investigations, new recruitment practices, a tertiary partnership for transport safety investigator training with RMIT University, and new technologies to support investigations such as remotely piloted aircraft and 3D modelling.

The ATSB has a well-deserved reputation of excellence – and for that I acknowledge Mr Hood’s transformational stewardship. It is without doubt that the ATSB has grown in both stature and importance under his watch. 

I would also like to acknowledge and thank our Chief Operating Officer, Mr Colin McNamara, who acted as Chief Commissioner and Chief Executive Officer from Mr Hood’s retirement until my appointment took effect on 2 September 2021. Mr McNamara shouldered a substantial load in acting as Chief Commissioner during an incredibly dynamic and demanding operating environment.  

May I also acknowledge the contributions of Ms Carolyn Walsh, who finished her more than 10-year term as an ATSB Commissioner in September 2020. The ATSB benefited greatly from her expertise in transport safety, occupational health and safety, risk management, and regulatory frameworks and governance.

In turn during 2020–21, we welcomed Ms Catherine Scott, who has extensive experience in rail safety and road transport, finance and risk management, and board directorships, with her appointment to the ATSB Commission in September 2020.

I look forward to working with Ms Scott and her fellow Commissioners, Chris Manning and Gary Prosser, to continue to ensure all ATSB staff are resourced and empowered to bring their expertise to the forefront. This then will allow me to deliver on my other responsibility to build on the ATSB’s long-term success by continuing to increase the relevance and value that our work brings to all those whom we are entrusted to deliver safety outcomes.  


The ATSB continues to work towards achieving our new performance measures established in our 2020–21 Corporate Plan. Through revised performance criteria, we are focused on improving our timeliness, demonstrating safety action taken in response to our investigations, ensuring our findings are defendable, and using our resources efficiently and effectively to achieve the greatest safety outcomes across our multiple modes of transport.

With fewer safety occurrence notifications reported to the ATSB during the year, we were not required to commence as many new investigations when compared to previous years. This allowed the ATSB to focus on, and close, several complex older investigations from early 2020. ATSB investigator resources were also allocated to support the design and build of the new purpose-built investigation management software system. The ATSB’s new Investigation Management System (AIMS) comes online in 2021–22 and is set to deliver significant productivity improvements through the removal of time-intensive manual processes. Additionally, the system’s cloud-based functionality will allow investigators to access data and upload evidence in-the-field on any device.

During 2020–21, the ATSB completed 62 occurrence investigations. Among the higher profile investigations published during the year were:

  • The collision with water of a de Havilland Canada DHC-2 Beaver aircraft at Jerusalem Bay, Hawkesbury River, New South Wales, on 31 December 2017.
  • Signal ME45 passed at danger involving suburban passenger train TP43 and near collision with another suburban passenger train, Bowen Hills, Queensland, on 10 January 2018.
  • The loss of control and collision with water of a Eurocopter EC120B helicopter at Hardy Reef, Whitsundays, Queensland, on 21 March 2018.
  • The fire on board the self-unloading bulk carrier Iron Chieftain at Port Kembla, New South Wales, on 18 June 2018.
  • The collision with terrain involving an AS350 helicopter during powerline stringing operations 60 km east of Woomera, South Australia, on 20 March 2019.

ATSB investigations place considerable focus on identifying safety issues that can be addressed by the parties that are ultimately responsible and best positioned for managing risk. This includes both operators and regulators. In 2020–21, 59% of our completed systemic, defined and safety study investigations identified new safety issues.

In all, 60 safety issues were identified in the reporting period, of which the ATSB determined 33 had been adequately addressed by 30 June 2021.

The ATSB is steadfast in its commitment that all published investigations are factually accurate, defendable and evidence-based. Accuracy of investigation findings remain integral to ensuring industry and government confidence in ATSB safety information in order to take action to improve transport safety. Consequently, I am pleased to confirm no changes to published investigations findings were required in 2020–21.

In the delivery of rail safety investigation services in New South Wales and Victoria, the ATSB has a collaboration agreement with independent investigation agencies in those states who conduct investigations under the Commonwealth’s Transport Safety Investigation Act 2003 (TSI Act). In 2020–21, the ATSB published and promoted eight rail safety investigations conducted by the New South Wales Office of Transport Safety Investigations (OTSI) and four rail safety investigations conducted by Victoria’s Chief Investigator, Transport Safety (CITS).

In 2020–21, the ATSB also:

  • Initiated 49 aviation occurrence investigations, three marine occurrence investigations and five rail occurrence investigations.
  • Published the statistical report, Aviation Occurrence Statistics 2010 to 2019 (rates update).
  • Published 39 occurrence briefs (38 aviation occurrences and one marine occurrence). Occurrence briefs are short reports that allow us to share safety learnings from a transport safety occurrence notification where the occurrence has not met the threshold of being subject to a transport safety investigation.
  • Processed 10,634 aviation transport safety occurrence notifications, 716 marine notifications and 882 rail notifications. From those, the ATSB safety reporting team identified 4,073 aviation and 294 marine accidents, serious incidents and incidents for the year. (In rail, the Office of the National Rail Safety Regulator (ONRSR) is responsible for processing all notifications from industry into occurrences in the Australian national rail occurrence database shared with the ATSB.)
  • Received and processed 198 notifications under the REPCON confidential reporting scheme, of which 75 were assessed and classified as meeting the REPCON criteria. During the year, 47 REPCON reports were completed, of which 18 (38%) resulted in safety action being taken by stakeholders.
  • Despite the limitations of the pandemic, participated in 27 key industry engagement events, including the International Confidential Aviation Safety Systems, the Rail Industry Safety and Standards Board’s Rail Safety Conference, and the Australian Association for Unmanned Systems' RPAS in Australian Skies Conference. Former Chief Commissioner, Greg Hood also hosted the International Transportation Safety Association’s Annual Conference.
  • Managed 361 media inquiries, used our in-house media studio to produce and distribute 32 packages of pre-recorded audio, video and video overlay content for distribution to national radio and TV outlets, and logged the publication and airing of 1,997 stories about the ATSB and its investigation activities by mainstream and transport industry media outlets. Of those, 1,261 stories (approximately 63%) carried safety messaging relating to our investigations.
  • Promoted a number of safety education campaigns, including highlighting the dangers of CO gas exposure in piston-engined aircraft, reminding pilots of the need to be aware of stop bars at major airports across Australia, and supported the TrackSAFE Foundation’s Rail Safety Week in August 2020 to promote safety for road users and rail passengers when interacting with the rail network.
  • Published a video to promote the safety messaging from the investigation into Beaver aircraft the collision with water accident on the Hawkesbury River, which included a high-fidelity animation of the aircraft’s flight path. This video has been viewed more than 6,700 times across all of our social media channels.
  • Continued to support our regional partners build transport safety investigation capacity, in particular via the ongoing involvement in the Australian Government Indonesia Transport Safety Assistance Package (ITSAP), and assisting Papua New Guinea consistent with the Memorandum of Understanding on Cooperation in the Transport Sector.
  • Supported external agencies by assisting Recreational Aviation Australia and the Civil Aviation Authority of the Philippines – Aircraft Accident Investigation and Inquiry Board to recover and analyse data from damaged recording devices.
  • Progressed the rationalisation of our accommodation footprint with the leasing of new premises for the Canberra central office and the Melbourne regional office. This ensures we have highly capable technical facilities to support our operational requirements and a more dispersed workforce that will enhance our ability to deploy to transport accident sites throughout Australia.
  • Established a project to transfer our website onto the GovCMS content management system website platform.
  • Supported the delivery of the third Graduate Certificate in Transport Safety Investigation course in partnership with RMIT University. The course was delivered online to a cohort of 22 consisting of six ATSB investigators, two investigators from the Office of Transport Safety Investigation NSW, and 14 students from a broad range of industry organisations.


In a challenging year for the transport industry, the ATSB continued to focus on improving transport safety through our independent transport safety investigations.

The COVID-19 pandemic has been a time of great uncertainty for the transport industry in general, none more so than aviation. Cognisant of these challenges, I am committed to ensuring that the ATSB continues to effectively apply our safety knowledge and expertise in identifying safety risks in industry, and in monitoring the return to safe and reliable air transport operations as the pandemic eases.

And as an operational agency, the ATSB will continue to deploy accident investigation teams where and when necessary during the pandemic, whenever it is safe to do so.

The challenges experienced by workplaces and workforces across the country over the past year are both generic as well as very individual and personal. One of my key responsibilities and my initial focus as Chief Commissioner and Chief Executive Officer will be to ensure we continue to have a well-supported workforce that delivers world-class transport safety investigations that contribute to a safe and efficient Australian transport industry.

Angus Mitchell

Chief Commissioner

Publication Mode
Publication date
Publication type
Publication Number
Annual Report 2020-21